R. A. 9048 Form No. 4.

1 (LCRO)

Republic of the Philippines
CITY CIVIL REGISTRAR’S OFFICE
City of Davao

Republic of the Philippines} Petition No. _______________
City of Davao……………..}SS.
x­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­x

I,   (Petitioner),   of   legal   age,   Filipino,   single,   and   a   resident   of

_________________________, under oath, do hereby depose and state that:

1. I am the attorney­in­fact of Mrs. ____(parent)______ by virtue of a
Special   Power   of   Attorney   as   appearing   in   the   notarial   books   of
Notary   Public   ________________   under   notarial   entries   Doc.   No.
100; Page No. 20; Book No. CCXXXI; Series of __________, for
purposes of, among others, processing and facilitating the petition for
change of  name of  her son, _____(child)_____, and such all other
requirements   and   papers   with   all   government   offices   that   are
necessary and desirable to change the said name of her son;

2. I am the petitioner seeking the change of First Name of the Certificate
of Live Birth of _____(child)_____, who is the son of my principal,
Mrs. __________(parent)_________;

3. ____(Child)______   was   born   on   _____________   and   registered   at

Cagayan de Oro, Misamis Oriental, Philippines;

4. The   birth   was   registered   under   Registry   No.   ___________   at   the

Local Civil Registrar of Cagayan de Oro City;

5. The first name to be changed is from “Mikki” to “Mikki Mousu”;

6. The   ground   for   filing   this   petition   is   that   He   has   habitually   and
continuously used  “Mikki Mousu”  and he is publicly known in the
community with that first name;

7. I submit the following documents to support this petition:

a. Secondary Permanent Record issued by _________________;
b. Baptismal   Certificate   as   issued   on   ____________   of   the
Archdiocese of Cagayan de Oro;
c. School Identification Card;
d. National Bureau of Investigation Clearance issued on February 5,
2013;
 e. Police Clearance;
f. Community Tax Certificate issued on February 4, 2013 at Davao
City;
g. Barangay  Certification issued  on  February 4,  2013 at  Buhangin
District, Davao City;

8. He   has   not   filed   any   similar   petition   and   that,   to   the   best   of   my
knowledge,   no   other   similar   petition   is   pending   with   any   LCRO,
Court or Philippine Consulate;
9. He has no pending criminal, civil or  administrative case  as  in any
court or any quasi­judicial body;
10.I am filing this petition at the LCRO of Cagayan de Oro, Misamis
Oriental,   in   accordance   with   R.A.   No.   9048   and   its   implementing
rules and regulations.

Atty. ______________
Petitioner

VERIFICATION

I,   ________________,   the   petitioner,   hereby   certify   that   the

allegations  herein  are true and  correct  to  the  best  of  my  knowledge  and
belief.

Atty. __________________
Petitioner

SUBSCRIBED AND SWORN to before me this 6th day of February,
2013   at   Davao   City,   Philippines,   with   the   petitioner   exhibiting   his
Taxpayer’s Identification Card with No. _______________ issued on 06­18­
2010.

Doc. No. _____;
Page No. _____;
Book No. ____;
Series of 2013.
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For C/MCR use only

ACTION TAKEN BY C/MCR

(Provide basis for the action taken.)

□ Granted □ Denied
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___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

Date ________________ ATTY. LEO ANTHONY R. BRACEROS

City/Municipal Civil Registrar
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For CRG use only

ACTION TAKEN BY CRG

(Provide basis for the action taken.)

□
Granted Denied □
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___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

Date ________________ _______________________

Civil Registrar General
Payment of filing fee (Please attach copy of the official receipt.)
O.R. No. ____________
Amount Paid ____________
Date Paid ____________