REPUBLIC OF THE PHILIPPINES

REGIONAL TRIAL COURT

FOURTH JUDICIAL REGION
Branch ________
Dasmariňas, Cavite

IN THE MATTER OF CANCELLATION/

CORRECTION OF ENTRIES IN THE
CERTIFICATE OF LIVE BIRTH OF
________________,

_________________________
Petitioner,

---versus--- Special Proc. No. _________

CIVIL REGISTRAR OF ___________,

__________ AND ALL PERSONS/ENTITIES
WHO/WHICH MAY BE AFFECTED THEREBY,
Respondents.

x--------------------------------------x

PETITION

Petitioner, through the undersigned counsel and to this

Honorable Court, most respectfully states that:

1. Petitioner is of legal age, Filipino, single, a resident of

________________________________ and the mother and guardian
of her minor child – ________________________; whereas
Respondent - Civil Registrars are public officers in-charge of the
registration and cancellation/correction of entries in the civil registrar
where the fact of birth of the said minor child was registered, which
registrar is located at Ground Floor, City Hall, City of Dasmariñas;

2. Petitioner conceived and gave birth to her child on

November 13, 1995 at De La Salle University Medical Center,
Dasmariňas, Cavite, out of wedlock with Kazuya Terauchi, which fact
of birth was registered on ___________________ before the Office of
Respondent Civil Registrar of ________________ under Civil Registry
No. __________. Copy of the Certificate of Live Birth of __________
is hereto attached as Annex “A;”

3. Prompted by the misbelief that her child, being born out of

wedlock, could not utilize the surname of her father – ___________,
and that it is more convenient and easy to process the registration of
her child’s birth if she was married with _______. Petitioner supplied
erroneous information as regards the date and place of her marriage
with ___________;

5. Petitioner misrepresented in her application for the

registration of birth of her child that she and ___________ were
married on ___________ in Japan, when the truth of the matter is
that they were and have not been married to this date. Copy of the
Certification issued by the Civil Registrar General attesting to the fact
that Petitioner has not been married to ___________ as their
marriage does not appear in the National Indices of Marriage is hereto
attached as Annex “B;”

6. As a result, “Entry No. 18” referring to the date and

place of marriage of the parents of the said minor child, and
consequently, “Entry No. 20” particularly the printed name of herein
Petitioner which was entered as –___________, instead of
___________, of Certificate of Live Birth of the child are false and
misleading. Entry No. 18 in Annex A is hereto bracketed and marked
as Annex “A-1”. While, Entry No. 20 in Annex A is further bracketed
and marked as Annexes “A-2”;

7. In order to correct the aforementioned misinformation and

erroneous entries in the Certificates of Live Birth of her minor child,
Petitioner hereto files the instant Petition pursuant to Rule 108 of the
Revised Rules of Court;
 8. ___________, the father of the above-named child, who
has been permanently residing in Japan did not acknowledge nor
admit paternity over the said child as he did not sign the Letter of
Acknowledgment in the Certificate of Live Birth of ___________.

PRAYER

WHEREFORE, premises considered, it is most respectfully prayed

to this Honorable Court that an Order be issued directing the herein
Respondent – Civil Registrars to cancel the information supplied as
the date and place of marriage of parents in “Entry No. 18” and to
correct “Entry No. 20”, particularly the printed name of the herein
Petitioner from ___________ to ___________ and to correct the
surname of the minor child from ___________ to ___________ in the
Certificate of Live Birth of her minor child ___________.

Other reliefs just and equitable are likewise prayed for.

___________ City for Dasmariňas City. April __________, 2013.

___________
Counsel for the Petitioner
___________
___________

REPUBLIC OF THE PHILIPPINES)

CITY OF ___________ )SS

VERIFICATION AND CERTIFICATION

AGAINST FORUM-SHOPPING

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

___________, after having been duly sworn to in accordance with law,
do hereby depose and state that:

1. I am the Petitioner in the foregoing Petition and I have

caused the preparation of the same, the contents of which are all true
and correct to the best of my personal knowledge, information and
belief;
 2. I certify that neither have I commenced nor is there any
pending Petition of similar nature before any court, tribunal or quasi-
judicial agency, and if I should hereafter learn that the same or similar
Petition has been filed or is pending in any court, tribunal or quasi-
judicial agency, I shall report the fact within five (5) days therefrom to
this Honorable Court.

IN WITNESS WHEREOF, I have hereunto set my hand this

____________ day of April, 2013 in ___________ City.

___________
Affiant

SUBSCRIBED AND SWORN to before this ______ day of ________________,

20___ at _____________________________.

NOTARY PUBLIC

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of _____;