Checklist of Requirements as attached to the Petition for Administrative Adoption with Application for

Rectification of Simulated Birth Record

Name of Petitioner/s: _________________________________________ Age: ________ Date of Birth: _________________

_________________________________________ Age: ________ Date of Birth: _________________
Referring Party/ Agency: _____________________________________________________________________________________
Contact Person/Designated and Position: ________________________________________________________________________
Contact Number/s: ___________________________ Email Address: _________________________________________________

REQUIREMENTS SUBMITTED:

SOURCE OF DOCUMENT COMPLIED

REQUIREMENTS (Concerned Office/Person) (INDICATE REMARKS
EITHER YES
OR NO)
1. Authenticated copy of Simulated Birth Certificate of the Philippines Statistical Authority
child, authenticated birth record of the adopter(s) (PSA)
2. Notarized Affidavit of Admission Forms available at SWDO /
(if the simulation of the birth was done by a third person) ARRS Regional Office
3. Certification issued and signed from Punong Barangay
(stating that the petitioner is a bonafide resident; the Punong Barangay
child has been living with the petitioner for at least
three years prior to March 29, 2019; the petitioner is
indigent if applicable)
4. Notarized Affidavit Forms available at SWDO /
(at least two disinterested persons) ARRS Regional Office
5. Original Copy of CDCLAA issued by DSWD
(except if adult or relative within 4th degree of Local Social Worker (SWDO)
consanguinity / affinity)
6. Oldest and recent photographs of the prospective
adoptee and the petitioner(s) taken within the last Petitioner/s
three (3) months prior for the filing of the petition
7. Certification of Attendance by the petitioner(s) Regional Office (ARRS)
(proof of attending the pre-adoption, fora and seminar)
8. Marriage Certificate of adopter, Decree of Annulment,
Declaration of Nullity of Marriage/ Decree of Legal Petitioner/s
Separation
9. Latest Physical/Medical Evaluation of the adopter(s) by Physician
a duly licensed physician
10. Psychological evaluation of adopter(s) by a duly signed Psychologist
licensed Psychologist (if applicable)
11. Latest NBI / Police Clearance Petitioner/s
12. Latest Income Tax return or any documents
(Certificate of Employment, Bank Certificate or Statement Petitioner/s
of Assets and Liabilities)
13. Authenticated Copy of the Negative Certification of Philippines Statistical Authority
Birth (PSA)
(to serve as basis in the late registration and issuance of
rectified birth record)
14. Certified True Copy of receipts as proof of payment of
the socialized fees in SWDO or DSWD Field Office SWDO / DSWD Field Office
(this requirements is on case to case basis and if the
petitioner(s) is/are assessed by the social worker as
not indigent)
15. Consent from appropriate person(s):
a) The prospective adoptee, if ten years of age or
above;
b) The petitioner’s legitimate and adopted
daughters/sons, ten years of age or over, if Petitioner/s
any;
c) The petitioner illegitimate daughters/sons, ten
years of age or over, if living with said
adopter/s, if any; and,

d) The spouse of the adoptee, if any.

In case if the petitioner(s) is a foreign national married to
a Filipino, he/she must submit the following:

● Residence in the Philippine for at least three (3) Petitioner/s

continuous years
● Certification of legal capacity to adopt in his/her
country, and that his/her government allows the
adoptee to enter his/her country as his/her
adopted son or daughter

Received by: ___________________________________ Date: _____________________

Name of Social Worker
_______________________________________________________________ __________________
Petitioner’s Copy

Received by: ________________________________________ Date: __________________________

Name of Social Worker

Page 1-1 RA 11222 – Simulated Birth and Rectification Act

Page 1-1 RA 11222 – Simulated Birth and Rectification Act