VERIFICATION

I, , the petitioner, hereby certify that the allegations

herein are true and correct to the best of my knowledge and belief.

Signature over printed name of petitioner

SUBSCRIBED AND SWORN to before me this 16

th
day of September 2022 in the city/municipality
of Parañaque City , petitioner exhibiting his valid Identification Card with No.
issued at on .

Doc. No.
Page No.
Book No.
Series of 2022.

For C/MCR use only

ACTION TAKEN BY THE C/MCR

Granted Denied (Provide the basis for denial)

Date:

For CRG use only

ACTION TAKEN BY CRG

Affirmed Impugned

Date:

Civil Registrar General

Payment of filing fee (Please attach copy of the official receipt)

O.R. No.
Amount paid ₱
Date paid