Republic of the Philippines )

Province of Laguna ) S.S.

City of Cabuyao )
x-----------------------x

AFFIDAVIT OF ATTENDANT AT BIRTH

I, Dr. ____________________________, Filipino, of legal age, (single / married /

widow), and a resident of ________________________________________________,
Philippines, having been duly sworn in accordance with law, hereby depose and state:

That I am a duly-license medical doctor, practicing at ____________________

(Hospital/Clinic) with Professional License No. ___________________ issued on
____________________ at ______________________;

That on or about ______________(time) of ________________(date), I

personally attended to a patient named __________________________________ in
giving birth by (normal delivery/caesarian section) to a baby (boy/girl) whom they named
as ______________________________;

That I execute this Affidavit to attest to the truth of the foregoing facts and for any
other legal purpose that this Affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set our hands this _______________,

at City of Cabuyao, Laguna, Philippines.

_________________________
Affiant

SUBSCRIBED AND SWORN to before me, this _________________, by the

Affiant whom I have identified through competent evidence of identity and who exhibited
his/her _______________________________.

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 20___.