MunicipalFormNo.

102(Tobeaccomplishedinquadruplicate)
(revisedJanuary1993)

RepublicofthePhilippines
OFFICEOFTHECIVILREGISTERGENERAL
CERTIFICATEOFLIVEBIRTH
(Filloutcompletely,accuratelyandlegibly,UseInkorTypewriter.
PlaceXbeforetheappropriateanswerinItems2,5a,5band19a)

FOROCRGUSEONLY:

Registryno.

Province_________________________________________________________
City/Municipality______________________________________________
1.NAME(First)(middle)(last)

2.SEX
3.DATEOFBIRTH(day)(month)(year)

__________1Male__________2Female
4.PLACEOF(NameofHospital/clinic/institution/(city/municipality)(province)
BIRTHHouseNo.,Street,Barangay)

C
H
I
L 5a.TYPEOFBIRTH
D ____________1Single_____________2Twin

b.IFMULTIPLEBIRTH,CHILDWAS
________1First_________2Second

________3others,Specify___________

___________3Triple,etc

c.BIRTHORDER(livebirthsandfetaldeaths
includingthisdelivery)
____________(first,second,third,etc.)

d.WEIGHTATBIRTH

_______________grams

6.MAIDEN(First)(middle)(last)
NAME

M
O
T
H
E
R

7.CITIZENSHIP

8.RELIGION

9a.Totalnumberof
b.No.ofChildrenStillc.No.ofChildren
Childrenborn
livingincludingbornalivebut
Alive:___________
thisbirth:__________arenowdead:_______

11.Ageatthetime
10.OCCUPATION
Ofthisbirth:

______________ years

12.RESIDENCE(HouseNo.,Street,Barangay)(City/Municipality)(Province)
U

F
A
T
H
E
R

REMARKS/ANNOTATION

PopulationReferenceNo.

TOBEFILLEDUPATTHE
OFFICEOFTHECIVIL
REGISTRAR

41

48

4950

56

61

6264

13.NAME(First)(middle)(last)

14.CITIZENSHIP

15.RELIGION

16.OCCUPATION

707274

17.Ageatthetime
Ofthisbirth:
______________ years
U

18.DATEANDPLACEOFMARRIAGEOFPARENTS(Ifnotmarried,accomplishaffidavitof
Acknowledgement/AdmissionofPaternityattheback)

19a.ATTENDANT
_________ 1Physician _________ 2Nurse _________ 3Midwife
U

_________ 4Hilot(TraditionalMidwife) _________ 5Others(Specify)

U

19b.CERTIFICATIONOFBIRTH
IherebycertifythatIattendedthebirthofthechildwhowasbornaliveat__________oclock
am/pmonthedatestatedabove.

Signature_________________________________Address________________________________
NameinPrint_____________________________________________________________________
TitleofPosition _____________________________ Date
U

___________________________________

20.INFORMANT

Signature_________________________________Address________________________________

7679

81

8687

8891

NameinPrint_____________________________________________________________________

TitleofPosition_____________________________Date___________________________________
93
21.PREPAREDBY22.RECEIVEDATTHEOFFICEOF

THECIVILREGISTER

Signature_________________________________Signature______________________________ 94

NameinPrint______________________________NameinPrint___________________________
TitleofPosition_____________________________TitleofPosition__________________________
Date_____________________________________Date___________________________________

Forbirthsbefore3August1988/onorafter3August1988

AFFIDAVITOFACKNOWLEDGMENT/ADMISSIONOFPATERNITY

We/I, _______________________________________ and _________________________________________

U

Parents/parentofthechildmentionedinthisCertificateofLiveBirthdoherebysolemnlyswearthattheinformationcontainedhereinand
trueandcorrecttothebestofour/myknowledgeandbelief.

____________________________________ _____________________________________
(SignatureofFather)(SignatureofFather)
U

CommunityTaxNo. _________________________ CommunityTaxNo. __________________________

DateIssued_ ________________________________ DateIssued __________________________________
PlaceIssued __________________________ PlaceIssued __________________________

SUBSCRIBEDANDSWORNtobeforemethis __________ dayof __________________________________,_________________

at _____________________________________________________________________________________ ,Philippines.

______________________________________ ________________________________________
U

(SignatureofAdministeringOfficer)(Title/Designation)

________________________________________________ __________________________________________________
(NameinPrint)(Address)
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Notapplicableforbirthsbefore27February1931

AFFIDAVITFORDELAYEDREGISTRATIONOFBIRTH
(Eitherthepersonhimselfif18yearsoldorover,orfather/mother/guardianmayaccomplishthisaffidavit)

I,_____________________________________________________________________________________,legalage,single/married
andwithresidenceandpostaladdressat_____________________________________________________________________________________,
afterhavingbeendulysworntoinaccordancewithlaw,doherebydeposeandsay:

1. ThatIamtheapplicantforthedelayedregistrationofmybirth/ofthebirthof
__________________________________________________ .
2. ThatI/he/shewasbornon _______________________ at ____________________________________________
3. ThatI/he/shewasattendedatbirthby ______________________________________________ whoresidesat
_________________________________________________________________.
4. ThatI/he/sheisacitizenof ____________________________________________.
5. Thatmy/his/herparentsweremarriedon _______________________ at __________________
______________________________________.
NotMarriedbutwasacknowledgebymy/his/herfatherwhosenameis
______________________________________________ .
6. Thatthereasonforthedelayinregisteringmy/his/herbirthwasdueto ____________________________________
___________________________________________________________________ .
7. Thatacopyofmy/his/herbirthcertificateisneededforthepurposeof ____________________________________
____________________________________________________________________ .
8. (Fortheapplicantonly)ThatIammarriedto ____________________________________________________ .
(FortheFather/mother/guardian)ThatIamthe __________________________ ofthesaidperson.

__________________________________________
U

(SignatureofAffiant)
CommunityTaxNo_________________________________
DateIssued_______________________________________
PlaceIssued_______________________________________

SUBSCRIBEDANDSWORNtobeforemethis__________dayof_____________________________________,______________________
at______________________________________________________________________________________,Philippines.

__________________________________________________________________________________________
(SignatureofAdministeringOffice)(Title/Designation)

__________________________________________________________________________________________
(NameinPrint)(Address)