REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ZAMBOANGA DEL SUR)

MUNICIPALITY OF MOLAVE )ss
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AFFIDAVIT

I, _____________________, of legal age, Filipino, married, and a resident of

Dipolo, Molave, Zamboanga del Sur, after having been duly sworn to in accordance with
law, hereby depose and state, THAT:

1. I am the applicant for the delayed registration of my daughter’s birth,

___________________, who unluckily a retarded being ;

2. She was born on ____________ at Tambulig, Zamboanga del Sur;

3. She is a citizen of Dipolo, Molave Zamboanga del Sur;

4. The above-named mentioned is my legitimate child;

5. The reason for the delay in registering her birth was due to my excusable
negligence;

6. A copy of her birth certificate is needed for the purpose of processing her
PHILHEALTH NG MASA;

7. I am executing this affidavit to prove the veracity of the facts mentioned

herein and for whatever legal intents and purposes this affidavit may serve
best.

IN WITNESS WHEREOF, I have hereunto set my hand this 21 st day of

November, 2016 at Molave, Zamboanga del Sur, Philippines

____________________
Affiant
Postal ID No.N06160530395 P
Valid Until: 10/26/2019

SUBSCRIBED AND SWORN to before me this 21st day of November, 2016 at

Molave, Zamboanga del Sur, Philippines.

Doc. No.: 190;

Page No.: 38;
Book No.: XI;
Series of 2016.