Annex C - Certificate Of Live Birth

Municipal Form No. 103 (Revised January 1993)

REMARKS/ANNOTATION

(To be accomplished in quadruplicate)

Republic of the Philippines OFFICE OF THE CIVIL REGISTAR GENERAL

CERTIFICATE OF LIVE BIRTH (Fill out completely, accurately and legibly. Use ink or typewriter. Place X before the appropriate answer in items 2, 9, 13, 15, 16, 18, 19, 21 and 23.)

ProvinceIloilo ____________________________ Registry No. 1234 Jaro, Iloilo City City/Municipality ______________________ 1. NAME (First) (Middle) Santos Paul Peter

2. SEX

3. DATE OF BIRTH

 _____1 Male _____2 1 2016 January 2011 Female CJanuary

H I L

4. PLACE OF BIRTH Barangay Mohon,

D

(Name of Hospital/Clinic/Institution/ House No., Street, Barangay) Arevalo, Iloilo City

5a. TYPE OF BIRTH  

_____1 Single

(day)

Iloilo

______ 1 First

______ Triplet, etc.

______ 2 Second

this delivery) ______________ (first, second, third, etc.) 6. MAIDEN (First) Maria Caressa Mendoza

NAME M 7.Catholicism CITIZENSHIP Filipino Roman

b. No. of children still

children Oneborn (1) Zero (0) alive: One_________ (1)

____________ grams

(Middle) Santos

living including this birth: __________

H E 10. OCCUPATION Consultant RSalesNone

48

(Last)

49

50

c. No. of children

born alive but are now dead: _______

56

11. Age at the time o this delivery: ______ years

19 23

(House No./Street/Barangay) Barangay Calumpang,

(City/Municipality) Molo, Iloilo City,

Iloilo

(Province)

F 13. NAME (First) (Middle) (Last) Acosta dela Cruz AJuan Gregory T 14. CITIZENSHIP 15. RELIGION Roman Catholicism H Filipino E 16. OCCUPATION 17. Age at the time o this delivery: Vice President for Marketing of Iloilo Projects Corporation. R ______ years 23 18. DATE AND PLACE OF MARRIAGE OF PARENTS (if not married, accomplish Affidavit of Acknowledgement/Admission of Paternity at the back.) 10 March 2010

61 62

64

68

69

70

72

74

Jaro Cathedral, Jaro, Iloilo City

19a. ATTENDANT

________  1 Physician ________ 4 Hilot (Trditional Midwife)

3

41

d. WEIGHT AT BIRTH

8. RELIGION

9a. Total number of

TO BE FILLED UP AT THE OFFICE OF THE CIVIL REGISTRAR

_______ 3 Others, Specify _______

2 500

12. RESIDENCE

(Province)

b. IF MULTIPLE BIRTH, CHILD WAS

_____2  Twin

FOR OCRG USE ONLY Population Reference No.

(month)(year)

(City/Municipality)

c. BIRTH ORDER (live births and fetal deaths including

O T

(Last)

Dela Cruz

_______ 2 Nurse ________ 3 Midwife _______ 5 Others (Specify)

19b. CERTIFICATION OF BIRTH I hereby certify that I attended the birth of the child who was born alive at ____________ o’clock am/pm on the date stated above. Jaro, Iloilo City Signature ______________________________ Name in Print __________________________ Attending Physician Title or Position __________________________

Address ______________________________ _____________________________________ Date _________________________________

20. INFORMANT Signature ______________________________ Name in Print __________________________ Relationship to the child ___________________

Address ______________________________ _____________________________________ Date _________________________________

21. PREPARED BY

22. RECEIVED AT THE OFFICE OF THE CIVIL REGISTRAR

Signature ______________________________ Name in Print __________________________ Title or Position __________________________ Date ___________________________________

Signature _____________________________ Name in Print _________________________ Title or Position _________________________ Date _________________________________

76

79

81

86 88 93 94

87

91

For births before 3 August 1988/on after 3 August 1988 AFFIDAVIT OF ACKNOWLEDGEMENT/ADMISSION OF PATERNITY We/I, ________________________________ and ________________________________________ parents/parent of the child mentioned in this Certificate of Live Birth, do hereby solemnly swear that the information contained herein are true and correct to the 0best of our/my knowledge and belief. _______________________________

_______________________________

(Signature of Father)

(Signature of Mother)

Community Tax No. _________________ Date Issued ________________________ Place Issued ________________________

Community Tax No. _________________ Date Issued ________________________ Place Issued ________________________

SUBSCRIBED AND SWORN to before me this ___________ day of _____________________, _________ at ________________________________________________________________________, Philippines.

___________________________________

___________________________________

(Signature of Administering Officer)

___________________________________

(Title/designation)

___________________________________

(Name in Print)

(Address)

Not applicable for births before 27 February 1931 AFFIDAVIT FOR DELAYED REGISTRATION OF BIRTH (Either the person himself if 18 years old or over, or father/mother/guardian may accomplish this affidavit.)

I, ________________________________________________________, of legal age, single/married and with residence and postal address at _____________________________________________________, after having been duly sworn to in accordance with law, do hereby depose and say: 1. 2. 3. 4.

5.

6. 7. 8.

That I am the applicant for the delayed registration of my birth/of the birth of ______________________________________. That I/he/she was born on ______________________ at ______________________________. That I/he/she was attended at birth by _________________________________ who resides at _________________________________________________________________. That I/he/she is a citizen of __________________________________________.

That my/his/her parents were

married on ________________________ at _____________ __________________________________________. not married but was acknowledge by my/his/her father whose name is __________________________________________. That the reason for the delay in registering my/his/her birth was due to ________________________ ____________________________________________________________________. That a copy of my/his/her birth certificate is needed for the purpose of __________________________ ______________________________________________________________. (For the applicant only) That I am married to ______________________________________. ( For the father/mother/guardian) That I am the _______________________ of the said person.

_______________________________________________ (Signature of Affiant)

Community Tax No. _________________________ Date Issued ________________________________ Place Issued ________________________________

SUBSCRIBED AND SWORN to before me this _________ day of ________________, __________ at ____________________________________________________________________, Philippines. ___________________________________ (Signature of Administering Officer)

___________________________________ (Name in Print)

___________________________________ (Title/designation)

___________________________________ (Address)