Municipal Form No. 102
(Revised August 2016 )

(To be accomplished in quadruplicate using black ink)

 
Republic of the Philippines
OFFICE OF THE CIVIL REGISTRAR GENERAL

CERTIFICATE OF LIVE BIRTH

{{qrcode}}
Province
{{province_name}}
City/Municipality
{{municipality_name}}
Registry No.
{{reg_no}}
C
H
I
L
D
1. NAME
(First)
{{child_first_name}}
(Middle)
{{child_middle_name}}
(Last)
{{child_last_name}}
2. SEX
(Male/Female)
{{child_gender}}
3. DATE OF BIRTH
{{child_dob}}
4. PLACE OF BIRTH
(Name of Hospital/Clinic/Institution/
House No.,St.,Barangay)
{{hospital_name}}
(City/Municipality)
{{child_geo_municipality}}
(Province)
{{child_geo_province}}
5a. TYPE OF BIRTH
(Single, Twin, Triplet, etc)
{{child_type_of_birth}}
5b. IF MULTIPLE BIRTH, CHILD WAS
(First, Second, Third etc.)
{{total_child}}
5c. BIRTH ORDER
(Order of this birth to previous live births including fetal death)
(First, Second, Third etc.)
{{birth_order}}
6. WEIGHT AT BIRTH
{{weight_at_birth}} (grams)
M
O
T
H
E
R
7. MAIDEN NAME
(First)
{{mother_first_name}}
(Middle)
{{mother_middle_name}}
(Last)
{{mother_last_name}}
8. CITIZENSHIP
{{mother_citizenship}}
9. Religion
{{mother_religion}}
10a. Total number of children born alive
{{alive_children_number}}
10b. No. of children still living including this birth
{{no_of_children_still_living_including_this_birth}}
10c. No. of children born alive but are now dead
{{no_of_children_born_alive_but_are_now_dead}}
11. Occupation
{{mother_occupation}}
12. AGE at the time of this birth
(completed years)
{{mother_age_at_birth_time}}
13. Residence
(House No.,St.,Barangay)
{{mother_house_no}}
(City/Municipality)
{{mother_geo_municipality}}
(Province)
{{mother_geo_province}}
(Country)
{{mother_country}}
F
A
T
H
E
R
14. NAME
(First)
{{father_first_name}}
(Middle)
{{father_middle_name}}
(Last)
{{father_last_name}}
15. CITIZENSHIP
{{father_citizenship}}
16. Religion
{{father_religion}}
17. Occupation
{{father_occupation}}
18. AGE at the time of this birth
(completed years)
{{father_age_at_time_of_birth}}
19. Residence
(House No.,St.,Barangay)
{{father_house_no}}
(City/Municipality)
{{father_geo_municipality}}
(Province)
{{father_geo_province}}
(Country)
{{father_country}}
MARRIAGE OF PARENTS
20a. DATE
{{parents_marriage_date}}
20b. PLACE
(City/Municipality)
{{parents_geo_municipality}}
(Province)
{{parents_geo_province}}
(Country)
{{marriage_of_parents_country}}
21a. ATTENDANT
1 Physician
{{phy}}
2 Nurse
{{nur}}
3 Midwife 4 Hilot (Traditional Birth Attendant)
{{mid}}
3 Hilot
{{hil}}
5 Others (Specify)
{{others}}
{{if_other_position}}
21b. CERTIFICATION OF ATTENDANT AT BIRTH
(Physician, Nurse, Midwife, Traditional Birth Attendant/Hilot, etc.)
I hereby certify that I attended the birth of the child who was born alive at {{specific_birth_time_input}} on the date of specified above.
Signature
Signature
Name in Print
{{attendant_certificate_name_in_print}}
Title or Position
{{attendant_title_or_position}}
Address
{{attendant_certficate_address}}
 
Date
{{attendant_certificate_date}}
22. CERTIFICATION OF INFORMANT
I hereby certify that all information supplied are true and correct to my own knowledge and belief.
Signature
Signature
Name in Print
{{informant_certificate_name_in_print}}
Relationship to the Child
{{relationship_to_the_child}}
Address
{{informant_certficate_address}}
Date
{{informant_certificate_date}}
23. Prepared By
 
Signature
{{pre_by_signature}}
Name in Print
{{pre_by_name}}
Title or Position
{{pre_by_position}}
Date
{{pre_by_date}}
24. RECEIVED BY
Signature
{{rec_by_signauture}}
Name in Print
{{rec_by_name}}
Title or Position
{{rec_by_Position}}
Date
{{rec_by_date}}
25. Registered at the office of the civil registrar
Signature
{{reg_at_signature}}
Name in Print
{{reg_at_name}}
Title or Position
{{reg_at_position}}
Date
{{reg_at_date}}
Remarks/annotations (For LCRO/OCRG Use Only)
to be filled-up at the office of the civil registrar
8
9
11
13
15
16
17
19

AFFIDAVIT OF ACKNOWLEDGEMENT/ADMISSION OF PATERNITY

(For births before 3 august 1988)
(For births on or after 3 august 1988)
I/We
{{un_fathername}}
and
{{un_mothername}}
of legal age, am/are the natural mother and/or father of
{{un_child}}
, who was born on
{{un_childdob}}
at
{{un_address}}
I am / We are executing this affidavit to attest to the truthfulness of the foregoing statements and for purposes of acknowledging my/our child.
(Signature Over Printed Name of Father)
(Signature Over Printed Name of Mother)
SUBSCRIBED AND SWORN
to before me this
 
day of
 
,
 
by
 
 
and
 
, who exhibited to me his/her
 
CTC/valid ID
 
issued on
 
at
 
 
 
Signature of the Administering Officer
Position/Title/Designation
Name in Print
Address
 

AFFIDAVIT FOR DELAYED REGISTRATION OF BIRTH

(To be accomplished by the hospital/clinic administrator, father, mother or gurdian or the person himself if 18 years old or over.)
{{late_applicant_name}}
, of legal age, single/married/divorced/widow/widower, with residence and postal address at
{{late_applicant_address}}
 
after having been duly sworn in accordance with law, do hereby depose and say:
1. That I am the applicant for the delayed registration of :
 
my birth in
{{my_add}}
on
{{my_dob}}
 
the birth
{{other_child_name}}
who was born in
{{other_child_add}}
 
on
{{other_child_dob}}
.
2. That I/he/she was attended at birth by
{{att_name}}
who resides at
{{att_address}}
3. That I/he/she is a citizen of
{{nationlity_of_child}}
.
4. That my/his/her parents were
 
married on
{{la_parent_mdate}}
at
 {{la_parent_maddress}}
 
not married but I/he/she was acknowledged/not acknowledged by my/his/her father whose name is
{{la_un_fatername}}
5. That the reason for the delay in registering my/his/her birth was
{{reason_of_later}}
.
6. (For the applicant only) That I am married to
{{my_iam_married_to}}
.
(If the applicant is other than the document owner) That I am the
{{my_relationship_to_the_child}}
of the said person.
7. That I am executing this affidavit to attest to the truthfulness of the foregoing statements for all legal intents and purposes.
In truth whereof, I have affixed my signature below this
 
day of
 
 
at
 
, Philippines.
 
 
 
{{la_informant_certificate_name_in_Print}}
(Signature Over Printed Name of Affiant)
SUBSCRIBED AND SWORN
to before me this
 
day of
 
,
 
at
 
 
, Philippines, affiant who exhibited to me his/her CTV/valid ID
 
 
 
issued on
 
at
 
 
 
Signature of the Administering Officer
{{reg_at_position}}
Position/Title/Designation
 
{{reg_at_name}}
Name in Print
{{municipality_name}}, {{province_name}}
Address
 

In the name of ALLAH

the merchiful, the compassionate

Municipal Form No. 102
(Revised August 2017, attachment)

(To be accomplished in quadruplicate using black ink)
Province
{{province_name}}
City/Municipality
{{municipality_name}}
 Registry No.
{{reg_no}}
1. NAME OF CHILD
(First)
{{child_first_name}}
(Middle)
{{child_middle_name}}
(Last)
{{child_last_name}}
2. DATE OF BIRTH
Gregorian Calendar {{child_dob}}
 
Hijrah Calendar {{higri_child_dob}}
3. ETHNICITY OF THE FATHER
      {{ethnicity_of_the_father}}  
4. ETHNICITY OF THE MOTHER
   {{ethnicity_of_the_mother}}  
5. INFORMANT
Signature
 
Name in print
{{informant_certificate_name_in_print}}
Relationship to the child
{{relationship_to_the_child}}
Address
{{informant_certficate_address}}
 
Date
{{informant_certificate_date}}