REPUBLIC OF THE PHILIPPINES

CITY OF MANILA

)
)s.s.

AF F I D AV I T

That I, __________________________, Filipino, married and with postal address c/o Jose
R. Reyes Memorial Medical Center, Manila after having been duly sworn to in accordance with
law, do hereby depose and say;
1.

That I am presently employed as Administrative Aide III at

__________________________, Rizal Avenue, Manila;

2.

That one of my duties is to type and register birth certificates;

3.

That sometime on ________________, __________________

_____________, gave birth to a baby ________;

4.

That the attending physician of _________________________

was Dr. __________________________________.

5.

That the ___________________________________________

__________________________________________________
__________________________________________________
hence, the delayed registration of the said document;

6. That I am executing this affidavit to attest to the truth of the foregoing facts
and for the purpose of late registration.
IN WITNESS WHEREOF, I have hereunto affixed my signature this _____day of
_______, 2011 at the City of Manila, Philippines.

______________________________

Affiant
SUBSCRIBED AND SWORN to me this _____ day of _______ , 2011 affiant exhibited
to me his Residence Certificate No.21731967 issued at Mandaluyong City on January 17, 2011.

_______________________________
Chief Administrative Officer