RA 9048 Form No. 4.

1 (LCRO)

(Devised 15 Aug. 2001)

REPUBLIC OF THE PHILIPPINES

LOCAL CIVIL REGISTRY OFFICE

Province of Pangasinan

CITY OF ALAMINOS (complete name of petitioner) (nationality/citizenship)

Republic of the Philippines )
(complete address)

Province of Pangasinan
)

City of Alaminos
)
Petition No. ______________
______________________) SS

PETITION FOR CHANGE OF FIRST NAME

I, ___________________________________________, of legal age, ____________________, and a resident of ____________________________________________________________________

after having been duly sworn to in accordance with law, hereby declare that:

I am a petitioner seeking correction of the clerical error in:

my Certificate of Live Birth

the Certificate of Live Birth of _________________________________________________

(complete name of owner)

who is my ___________________________________________________________________
(relation of owner to the petitioner)
2. I/He/She was born on __________________ at _____________________________________

(date of birth) (city/municipality)

___________________________________________, ________________________________.

(province)(country)

The birth was recorded under registry number _______________________________________.

The first name to be changed is from ____________________ to _______________________.

The grounds for filing this petition are the following: (Ground selected should be explained/justified in a
separate sheet of paper to be attached to this form.)
The first name is extremely difficult to write or pronounce;
I have/He/She has habitually and continuously used ________________ and I/He/She is publicly
known in the community with that first name;

The first name is tainted with dishonour;

The first name ridiculous;

The first name causes confusion:

Other: (Specify) _________________________________________________________

I submit the following documents to support this petition: (Use additional sheets, if necessary.)

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

I have not filed and similar petition and that, to the best of my knowledge, no longer similar petition is
pending with any LCRO, Court or Philippine Consulate.
I am filing this petition at the LCRO of _______________________, ______________________

(city/municipality) (province)

in accordance with RA No. 9048 and its implementing rules and regulations.

__________________________________
Signature over printed name of
petitioner
VERIFICATION
I, ____________________________________________, the petitioner, hereby certify that the
allegations herein are true and correct to the best of my knowledge and belief.

______________________________

Signature over printed name of petitioner

SUBSCRIBED AND SWORN to before me this ___________ day of _____________________

in the city / municipality of _____________________________, petitioner exhibiting his Community Tax

Certificate No. __________________ issued at __________________ on ______________________.

Doc. No.
________________

Page. No. ________________

__________________________
Book No.
________________
Administering Officer
Series of
________________

For C/MCR use only

ACTION TAKEN BY THE C/MCR

Granted Denied (Provide the basis for denial.)

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Date: _____________________ _____________________________

City / Municipal Civil Registrar

For CRG use only

ACTION TAKEN BY THE CRG

Affirmed Impugned

__________________________________________________________________________________

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Date: ____________________________ ___________________________

Civil Registrar General

Payment of filing fee (Please attach copy of the official receipt.)

O.R. No.
________________
Amount Paid
________________
Date paid
________________