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ANNEX A

APPLICATION FOR CORRECTION OF PERSONAL INFORMATION


I. Name : __________________________________________________
II. Office : __________________________________________________
III. Position : __________________________________________________
IV. Home Address : __________________________________________________

V. Information which is requested to be corrected:


[ ] Given Name From _____________________________________________
To _____________________________________________
[ ] Family Name From _____________________________________________
To _____________________________________________
[ ] Middle Name From _____________________________________________
To _____________________________________________
[ ] Date of Birth From _____________________________________________
To _____________________________________________
[ ] Place of Birth From _____________________________________________
To _____________________________________________

VI. Reason for or cause of discrepancy:


_____________________________________________________________________
_____________________________________________________________________

VII. Documents on file with the Commission where the information sought to be
corrected is recorded:

[ ] Examination Records:
Examination Taken : ______________________________________
Date Taken : ______________________________________
Place of Examination : ______________________________________
[ ] Appointment Paper:
Position : ______________________________________
Date Issued : ______________________________________
[ ] Personal Data Sheet:
Date Accomplished : ______________________________________
VIII. Supporting documents:
[ ] Certificate of Live Birth
Date the information was registered at the Municipal Civil Registrar
___________________________________________________
[ ] Others ___________________________________________________

I declare under the penalty of perjury that the information stated herein are
true and correct.

Name (in print) ________________________

Signature ________________________
Attach the following requirements Additional requirements when the
(Sections 105 and 106, Rule 19 of the 2017 submitted Certificate of Live Birth is issued on the
RACCS): basis of late registration: (original or duly Date Accomplished:
authenticated)
____________________
a. Orgininal Certificate of Live Birth duly a. Baptismal certificate, unless it has been lost or
authenticated by the Local Civil Registrar of destroyed during a war, fire, natural calamity or OR No.: _____________
the municipality or city where the birth was any other fortuitous event, in which case, a OR Date: ____________
registered or recorded or the PSA, or in its certification issued by the proper church authority
absence, a court order;
OR Amount: _________
must be submitted. If the requesting party was not
issued any baptismal cert or was not baptized, an
b. Personal Affidavit of Discrepancy; and affidavit attesting to such fact must be submitted;
b. Other employment, personal or school records
c. Photocopy of documents sought to be
which support the entry reflected in the belatedly
corrected.
registered birth cert and which entry is requested
to be reflected in the records of the Commission
as true and correct entry.

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