Republic of the Philippines )

Province of Bohol )
Municipality of Carmen ) S.S.

SELF-AFFIDAVIT
(re: Late Registration of Death)

I, MANOLITO D. MACABUDBUD, Filipino, of legal age, married and a resident of

Nueva Fuerza, Carmen, Bohol, after being sworn in accordance with law, hereby depose and say:

1. That I am the son the late AMADIA DAG-UM, who died last December 21, 1998 at
Nueva Fuerza, Carmen, Bohol;

2. That upon checking the records of the Philippine Statistics Authority (PSA), I found out
that record of death of my late mother is not found in their office;

3. That I was on the belief that the registration of death of my late mother was already
processed at our Local Civil Registrar (LCR) in Carmen, Bohol, Philippines;

4. That I was surprised to find out that the record of death of my late mother is not existing
in the records of our LCR;

5. That I am executing this affidavit to support the application for the late registration of the
death of my late mother at the LCR, Carmen, Bohol, Philippines;

6. That I further attest to the truth of the foregoing statements for whatever other legal
purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 9 th day of January, 2023 at
Carmen, Bohol, Philippines.

MANOLITO D. MACABUDBUD
Affiant
Senior Citizen ID No. 4057
Issued by the Office of the Senior Citizens Affairs
Carmen, Bohol

SUBSCRIBED AND SWORN TO before me this 9th day of January, 2023 at Carmen,
Bohol, Philippines.