Republic of the Philippines }

City of Calamba }s.s.

SWORN STATEMENT

I, ________________, of legal age, single, Filipino citizen and resident of Brgy. Looc,
Calamba City, Laguna, after having been duly sworn to in accordance with law do hereby depose
and state:

1. That I am the mother of __________________ who was born on __________________

in ________________________, Calamba City, Laguna and to father
______________________________;

2. That I was not able to cause the registration of her birth with the Office of the Local Civil
Registrar, Calamba City, Laguna due to my negligence and lack of necessary
requirements needed for registration of her birth;

3. That it is only now that I am causing the registration of the fact of his birth with the
Office of the Local Civil registrar, Calamba City, Laguna;

4. That I executed this affidavit to attest to the truth of all the facts mentioned herein and for
whatever legal intents and purposes this may serve.

IN WITNESS WHEREOF, I hereunto affixed my signature this 15th day of April 2015,
at Calamba City.

________________
Affiant
CEI: CTC NO. 18535910