RA 9048/RA 10172 Form No. 1.

1 (LCRO)
(Modified 7 January 2013)

Republic of the Philippines

Local Civil Registry Office
Province: _________________________
City/Municipality: _________________________

Republic of the Philippines )

________________________) S.s Petition No. ________________________

PETITION FOR CORRECTION OF CLERICAL ERROR

IN THE CERTIFICATE OF LIVE BIRTH

I, _________________________________________________, of legal age, ____________________, and

(complete name of petitioner) (nationality/citizenship)
a resident of _______________________________________________________________________, after having
(complete address)
been duly sworn to in accordance with law, hereby declare that:

1) I am the 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)
3) The birth was recorded under registry number __________________.
4) The clerical error(s) to be corrected is (are):

Item Description From To

No.

5) The facts/reasons for filing this petition are the following: (Use additional sheet, if necessary)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

6) I submit the following documents to support this petition: (Use additional sheet if necessary)
a) _______________________________________________________________________________________
b) _______________________________________________________________________________________
c) _______________________________________________________________________________________
d) _______________________________________________________________________________________
e) _______________________________________________________________________________________
f) _______________________________________________________________________________________
g) _______________________________________________________________________________________
h) _______________________________________________________________________________________

7) I have/He/She 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.
8) I am filing this petition at the CCRO of _____________________________, ___________________________
in accordance with R.A. No. 9048 / R.A. 10172 and its (city/municipality)
implementing rules and regulations. (province)

___________________________________
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/her ____________________________________________ issued at __________________ on
____________________.

___________________________________
Administering Officer

Doc. No.
Page No.
Book No.
Series of
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For C/MCR use only
ACTION TAKEN BY THE CCR
(Provide the basis for the action taken.)
Granted Denied

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Date: ______________________
City/Municipal Civil Registrar

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For CRG use only
ACTION TAKEN BY THE CRG
(Provide the basis for the action taken.)
Affirmed Impugned

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Date: _______________________
Civil Registrar General

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

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