Municipal Form No.

103 (To be accomplished in quadruplicate) REMARKS/ANNOTATION

(Revised January 1993)
Republic of the Philippines
OFFICE OF THE CIVIL REGISTAR GENERAL
CERTIFICATE OF LIVE BIRTH
(Fill out completely, accurately and legibly. Use ink or typewriter.
Place X before the appropriate answer in items 2, 9, 13, 15, 16, 18, 19, 21 and 23.)

ProvinceIloilo
____________________________
1234
Registry No.
Jaro, Iloilo City
City/Municipality ______________________
1. NAME (First) (Middle) (Last) FOR OCRG USE ONLY
Santos
Paul
Peter Dela Cruz Population Reference No.
2. SEX 3. DATE OF BIRTH (day) (month)(year)
 _____1 Male _____2
CJanuary
1 2016 January 2011 Female

H 4. PLACE OF (Name of Hospital/Clinic/Institution/ (City/Municipality) (Province) TO BE FILLED UP AT THE

I BIRTH House No., Street, Barangay) OFFICE OF THE CIVIL
L Barangay Mohon, Arevalo, Iloilo City Iloilo REGISTRAR

D 5a. TYPE OF BIRTH b. IF MULTIPLE BIRTH, CHILD WAS 41

  _____1 Single _____2
 Twin ______ 1 First ______ 2 Second
______ Triplet, etc. _______ 3 Others, Specify _______
c. BIRTH ORDER (live births and fetal deaths including d. WEIGHT AT BIRTH
2 500 this delivery)
______________ (first, second, third, etc.) ____________ grams 48
6. MAIDEN (First) (Middle) (Last)
Maria Caressa Mendoza Santos
NAME
M 7.Catholicism
Filipino
Roman CITIZENSHIP 8. RELIGION 49 50
O
T 9a. Total number of b. No. of children still c. No. of children
children
Oneborn
(1) living including born alive but
H alive: Zero (0)
One_________
(1) this birth: __________ are now dead: _______ 56
E 10. OCCUPATION 11. Age at the
RSalesNone
Consultant time o this delivery:
19
23 ______ years
61
12. RESIDENCE (House No./Street/Barangay) (City/Municipality) (Province)
Barangay Calumpang, Molo, Iloilo City, Iloilo

F 13. NAME (First) (Middle) (Last) 62 64

AJuan Gregory Acosta dela Cruz

T 14. CITIZENSHIP Roman Catholicism

15. RELIGION
H Filipino
E 16. OCCUPATION 17. Age at the 68 69
Vice President for Marketing of Iloilo Projects Corporation. time o this delivery:
R 23 ______ years
18. DATE AND PLACE OF MARRIAGE OF PARENTS (if not married, accomplish
Affidavit of Acknowledgement/Admission of Paternity at the back.) 70 72 74
10 March 2010 Jaro Cathedral, Jaro, Iloilo City

19a. ATTENDANT 76 79
________
 1 Physician _______ 2 Nurse ________ 3 Midwife
________ 4 Hilot (Trditional Midwife) _______ 5 Others (Specify)
19b. CERTIFICATION OF BIRTH
3 I hereby certify that I attended the birth of the child who was born alive at ____________ o’clock 81
am/pm on the date stated above.

Jaro, Iloilo City

Signature ______________________________ Address ______________________________
Name in Print __________________________ _____________________________________ 86 87
Attending
Title or Position Physician
__________________________ Date _________________________________

20. INFORMANT
Signature ______________________________
Name in Print __________________________
Relationship to the child ___________________
21. PREPARED BY
Signature ______________________________
Name in Print __________________________
Title or Position __________________________
Date ___________________________________
88 91
Address ______________________________
_____________________________________
Date _________________________________
93
22. RECEIVED AT THE OFFICE
OF THE CIVIL REGISTRAR
Signature _____________________________ 94
Name in Print _________________________
Title or Position _________________________
Date _________________________________
For births before 3 August 1988/on after 3 August 1988

AFFIDAVIT OF ACKNOWLEDGEMENT/ADMISSION OF PATERNITY

We/I, ________________________________ 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 0best of our/my knowledge and belief.

_______________________________ _______________________________
(Signature of Father) (Signature of Mother)

Community Tax No. _________________ Community Tax No. _________________

Date Issued ________________________ Date Issued ________________________
Place Issued ________________________ Place Issued ________________________

SUBSCRIBED AND SWORN to before me this ___________ day of _____________________, _________

at ________________________________________________________________________, Philippines.

___________________________________ ___________________________________
(Signature of Administering Officer) (Title/designation)

___________________________________ ___________________________________
(Name in Print) (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.)

I, ________________________________________________________, of legal age, single/married 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 ______________________________.
3. That I/he/she was attended at birth by _________________________________ who resides at
_________________________________________________________________.
4. That I/he/she is a citizen of __________________________________________.
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 __________________________
______________________________________________________________.
8. (For the applicant only) That I am married to ______________________________________.
( For the father/mother/guardian) That I am the _______________________ of the said person.

_______________________________________________
(Signature of Affiant)

Community Tax No. _________________________

Date Issued ________________________________
Place Issued ________________________________

SUBSCRIBED AND SWORN to before me this _________ day of ________________, __________

at ____________________________________________________________________, Philippines.

___________________________________ ___________________________________
(Signature of Administering Officer) (Title/designation)

___________________________________ ___________________________________
(Name in Print) (Address)