Republic of the Philippines ]

C I T Y O F D I P O L O G ]S.S.
X=======================/

AFFIDAVIT FOR
DELAYED REGISTRATION OF BIRTH
[and for out of town birth]

I, RODGINA A. ABAJAR, Filipino, of legal age, single, and a resident of Saluyong, Manukan,
Zamboanga del Norte, under oath, deposeth and sayeth:

That I was born on December 2, 1983, at the town of Kabasalan, province of Zamboanga
Sibugay;

That my parents are: Johnny A. Abajar and Rebecca J. Alburo, both of whom are now residing at
Cebu City;

That there are four of us in the family, and I am the third child;

That my fact of birth was accordingly reported to the proper authorities but there was a fire
which burned down the office, and my records were accordingly included so that the record of my birth
was not registered.

That although I am now 28 years old, I desire that my fact of birth be recorded, for purposes of
obtaining a passport.

That I am executing this affidavit in good faith to attest to the foregoing facts.

IN WITNESS WHEREOF, I have affixed my signature this 18th day of April, 2012, at Dipolog City,
Philippines.

RODGINA A. ABAJAR
Affiant

SUBSCRIBED AND SWORN to before me this 18th day of April, 2012, at Dipolog City, Philippines,
affiant showing her Postal Identification Card No. 8760649 valid until December 8, 2012, issued by
Philpost Manukan, Zamboanga del Norte.

Doc. No. ________: PETER Y. CO

Page No. ________: Notary Public
Book No. ________: Until December 31, 2012
Series of 2012 PTR No. 3185069 01-03-2012
IBP Lifetime No. 06834 07-18-2006
Roll No. 35379 05-20-1988
MCLE Compliance No. III-0001592 12-31-2008
Dipolog City Tel No. 065-212-9421