Municipal Form No 102 Revised January to Be 2007-2026

Municipal Form No. 102 Revised January 1993 To be accomplished in quadruplicate REMARKS/ANNOTATION Republic of the Philippines OFFICE OF THE CIVIL REGISTRAR GENERAL CERTIFICATE OF LIVE BIRTH Fill out completely accurately and legibly. Use ink or typewriter. Place X before the appropriate ANSWER IN ITEMS 2 5A 5B AND 19A. Province City/Municipality 1. NAME First Registry No* Middle 2. SEX FOR OCRG USE ONLY Last 3. DATE OF BIRTH day Population reference No* month year 1 Male 2 Female C H I L D 4. PLACE OF BIRTH Name of Hospital/Clinic/Institution/ House No* Street Barangay 5a* TYPE OF BIRTH b. 1 Single 2 Twin 3 Triplet. Etc* IF MULTIPLE BIRTH CHILD WAS 1 First 3 c* BIRTH ORDER live births and fetal deaths 6. MAIDEN NAME CITIZENSHIP 9a* Total number of children born alive born alive but are now dead c* No* of children No* of Children still living including this birth Age at the time of this birth years Province 8. RELIGION grams 10. OCCUPATION 12. RESIDENCE F A T E R 2 Second Others Specify d. WEIGHT AT BIRTH including this delivery M O TO BE FILLED UP AT THE REGISTRAR 18. DATE AND PLACE OF MARRIAGE OF PARENTS If not married accomplish Affidavit of Acknowledgement/Admission of Paternity at the back. 19a* ATTENDANT 1 Physician 2 Nurse 3 Midwife 4 Hilot traditional Midwife 5 Others Specify 19b. CERTIFICATION OF BIRTH I hereby certify that I attended the birth of the child who was born alive at o clock am/pm on the date stated above. Signature Address Name in Print Title or Position Date 20. INFORMANT Relationship to the child 21. PREPARED BY 22. RECEIVED AT THE OFFICE OF THE CIVIL REGISTRAR For this before 3 August 1988/on or after 3 August 1998 AFFIDAVIT OF ACKNOWLEDGEMENT/ADMISSION OF PATERNITY Well and parents/parent of the child mentioned in this Certificate of live Birth do hereby solemnly swear that the information contained herein are true and correct to the best of our/my knowledge and belief* Signature of Father Community Tax No* Date Issued Place Issued SUBSCRIBED AND SWORN to before me this day of Signature of Administering Officer Title/Designation Address Not applicable for births before 27 February 1931 AFFIDAVIT FOR DELAYED REGISTRATION OF BIRTH Either the person himself if 18 years old or over or father/mother/guardian may accomplish this affidavit. and with residence and postal address at after having been duly sworn to in accordance with law do hereby depose and say 1. That I am the applicant for the delayed registration of my birth/of the birth of 2. That I/he/she was born on at. 5. That my/his/her parents were married on at not married but was acknowledge by my/his/her father whose name is. 6. That the reason for the delay in registering my/his/her birth was due to 7. That a copy of my/his/her birth certificate is needed for the purpose of For the applicant only That I am married to. Use ink or typewriter. Place X before the appropriate ANSWER IN ITEMS 2 5A 5B AND 19A. Province City/Municipality 1. NAME First Registry No* Middle 2. SEX FOR OCRG USE ONLY Last 3. DATE OF BIRTH day Population reference No* month year 1 Male 2 Female C H I L D 4.