THE UNITED REPUBLIC OF TANZANIA NO.

230815C0557-B
REGISTRATION INSOLVENCY AND TRUSTEESHIP AGENCY (RITA)
APPLICATION FOR NEW BIRTH CERTIFICATE
(BIRTHS AND DEATHS REGISTRATION ACT)
(CAP 108)
CHILD PERSONAL INFORMATION
FIRST NAME DANIYAL MIDDLE NAME ABDULKARIM
SURNAME MUTEKULUZI OTHER NAMES --
DATE OF BIRTH 30-DEC-2022 SEX MALE
MOBILE NO 0710184950 EMAIL --
OCCUPATION MINOR NATIONALITY TANZANIA
EDUCATION LEVEL NEVER STUDIED PHYSICAL ADDRESS KIHONDA
ENTRY NO --

CHILD PLACE OF BIRTH CHILD PLACE OF DOMICILE

COUNTRY OF BIRTH TANZANIA COUNTRY OF DOMICILE TANZANIA
REGION OF BIRTH MOROGORO REGION OF DOMICILE MOROGORO
DISTRICT OF BIRTH MOROGORO DISTRICT OF DOMICILE MOROGORO
WARD OF BIRTH MAZIMBU WARD OF DOMICILE KIHONDA
STREET OF BIRTH MAZIMBU STREET OF DOMICILE KIHONDA

BIRTH INFORMATION
PLACE OF BIRTH HEALTH FACILITY TYPE OF BIRTH SINGLE
HOSPITAL NAME MAZIMBU HOSPITAL BIRTH NOTIFICATION --
WEIGHT AT BIRTH 3 PRESENT DURING DOCTOR
DELIVERY

MOTHER'S PERSONAL INFORMATION

FIRST NAME KHADIJA MIDDLE NAME SHABAN
SURNAME JUMA OTHER NAMES --
DATE OF BIRTH 30-DEC-1989 SEX FEMALE
MOBILE NO 0710184950 EMAIL --
ID TYPE NOT AVAILABLE ID NO --
OCCUPATION PEASANT(MKULIMA) NATIONALITY TANZANIA
IDENTIFICATION TYPE NOT AVAILABLE IDENTIFICATION NO --
NIN / NIDA -- ENTRY NO --
IS ALIVE YES PHYSICAL ADDRESS KIHONDA

MOTHER'S PLACE OF BIRTH MOTHERS'S PLACE OF DOMICILE

COUNTRY OF BIRTH TANZANIA COUNTRY OF DOMICILE TANZANIA
STREET KIHONDA REGION OF DOMICILE MOROGORO
DISTRICT OF DOMICILE MOROGORO
WARD OF DOMICILE KIHONDA

MOTHER'S PREGNANCY INFORMATION

NO OF PREGNANCY 2 NO OF CHILDREN 2
NO OF SAFE DELIVERIES 2 MONTH OF PREGNANCY 9
DEATHS BEFORE DELIVERY 0
FATHER'S PERSONAL INFORMATION
FIRST NAME ABDULKARIM MIDDLE NAME VICENT
SURNAME MUTEKULUZI OTHER NAMES --
DATE OF BIRTH 18-AUG-1988 SEX MALE
MOBILE NO 0710184950 EMAIL --
ID TYPE NOT AVAILABLE ID NO --
OCCUPATION LAWYER(MWANASHERIA) NATIONALITY TANZANIA
NIN -- ENTRY NO --
IS ALIVE YES PHYSICAL ADDRESS KIHONDA

FATHER'S PLACE OF BIRTH FATHER'S PLACE OF DOMICILE

COUNTRY OF BIRTH TANZANIA COUNTRY OF DOMICILE TANZANIA
STREET KIHONDA REGION OF DOMICILE MOROGORO
DISTRICT OF DOMICILE MOROGORO
WARD OF DOMICILE KIHONDA

INFORMANT'S PERSONAL INFORMATION

FIRST NAME ABDULKARIM MIDDLE NAME VICENT
SURNAME MUTEKULUZI OTHER NAMES --
DATE OF BIRTH 18-AUG-1988 SEX MALE
MOBILE NO 0710184950 EMAIL --
ID TYPE NOT AVAILABLE ID NO --
OCCUPATION LAWYER(MWANASHERIA) NATIONALITY TANZANIA
NIN -- ENTRY NO --
PHYSICAL ADDRESS KIHONDA

INFORMANT'S PLACE OF BIRTH INFORMANT'S PLACE OF DOMICILE

COUNTRY OF BIRTH TANZANIA COUNTRY OF DOMICILE TANZANIA
STREET KIHONDA REGION OF DOMICILE MOROGORO
DISTRICT OF DOMICILE MOROGORO
WARD OF DOMICILE KIHONDA

KIAPO: NATHIBITISHA KUWA MAELEZO NILIYOTOA HAPO JUU NI SAHIHI KWA KADIRI YA UFAHAMU WANGU NA NINAVYOAMINI
(ONYO: UNAKUMBUSHWA KWAMBA KIFUNGU CHA 29 (3) LA SHERIA YA KUANDIKISHA VIZAZI NA VIFO LIMEWEKA ADHABU KWA MAKOSA YA KUTOA TAARIFA ZA
UONGO)

SIGNATURE DATE OF APPLICATION AUGUST 15, 2023

TAARIFA ZA MSAJILI

MIMI
MSAJILI WA VIZAZI NA VIFO NIMEPOKEA MAELEZO YA MWOMBAJI CHINI YA KIAPO KWA
(W)
MAMLAKA NILIYOPEWA CHINI YA KIFUNGU CHA 20(2) SURA YA 108 LEO HII

SAINI YA MSAJILI TAREHE YA USAILI