(Affidavit of Doctor to Establish the Birth of a Person for Late Registration with the Civil

Registrar)

Republic of the Philippines) Province of _______________)S.S. City/Municipality of

___________)x

AFFIDAVIT

I, Dr. _________, Filipino, of legal age, (single / married / widow), and a resident of _________,
Philippines, having been duly sworn in accordance with law, hereby depose and state:

That I am a duly-license medical doctor, practicing at _________ (Hospital/Clinic) with

Professional License No. _________issued on ____________at ___________.

That on or about __time__ of __date__, I personally attended to a patient named _____________

in giving birth by (normal delivery/caesarian section) to a baby (boy/girl) whom they named as
_________;

That I execute this Affidavit to attest to the truth of the foregoing facts and for any other legal
purpose that this Affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set our hands this ___________,at ___________,
Philippines.

AFFIANT