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A (Certificate of Live Birth)

1) This document is a Certificate of Live Birth form used in the Philippines to record essential information about a newborn child such as name, date and place of birth, parents' names and other details. 2) The form collects information about the child like name, sex, date and place of birth as well as weight and type of birth. It also records identifying information about the parents such as names, citizenship, religion, occupation and residence. 3) Sections are included to record information about the birth attendant who certified the birth, the informant providing the details, and spaces for signatures of the preparer and receiver at the local civil registrar's office. Affidavits are provided for unmarried parents or cases

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3K views3 pages

A (Certificate of Live Birth)

1) This document is a Certificate of Live Birth form used in the Philippines to record essential information about a newborn child such as name, date and place of birth, parents' names and other details. 2) The form collects information about the child like name, sex, date and place of birth as well as weight and type of birth. It also records identifying information about the parents such as names, citizenship, religion, occupation and residence. 3) Sections are included to record information about the birth attendant who certified the birth, the informant providing the details, and spaces for signatures of the preparer and receiver at the local civil registrar's office. Affidavits are provided for unmarried parents or cases

Uploaded by

chate23
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Municipal Form No.

103
(Revised January 1993)

(To be accomplished in quadruplicate)

REMARKS/ANNOTATION

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.)

Province ____________________________
City/Municipality ______________________
1. NAME

(First)

(Middle)

4. PLACE OF
BIRTH

(Name of Hospital/Clinic/Institution/
House No., Street, Barangay)

(month)

5a. TYPE OF BIRTH

(City/Municipality)

(year)

6.

(Province)

b. IF MULTIPLE BIRTH, CHILD WAS


______ 1 First
______ 2 Second
_______ 3 Others, Specify _______

c. BIRTH ORDER

F
A
T
H
E
R

(day)

_____1 Male _____2 Female

_____1 Single
_____2 Twin
______ Triplet, etc.

M
O
T
H
E
R

FOR OCRG USE ONLY


Population Reference No.

(Last)

3. DATE OF BIRTH

2. SEX
C
H
I
L
D

Registry No.

(live births and fetal deaths including


d.
this delivery)
______________ (first, second, third, etc.)
MAIDEN
(First)
(Middle)

NAME
7. CITIZENSHIP

____________ grams

living including
this birth: __________

(Last)

(House No./Street/Barangay)

13. NAME

(First)

(City/Municipality)

(Middle)

14. CITIZENSHIP

49

born alive but


are now dead: _______
11. Age at the
time o this delivery:
______ years

10. OCCUPATION

12. RESIDENCE

50

(Province)

(Last)

56

61

62

64

68

69

70

72

15. RELIGION

16. OCCUPATION

17.

Age at the
time o this delivery:
______ years

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
________ 4 Hilot (Trditional Midwife)

48

c. No. of children

b. No. of children still

children born
alive: _________

41

WEIGHT AT BIRTH

8. RELIGION

9a. Total number of

TO BE FILLED UP AT THE
OFFICE OF THE CIVIL
REGISTRAR

_______ 2 Nurse
________ 3 Midwife
_______ 5 Others (Specify)

76

74

79

19b. CERTIFICATION OF BIRTH


I hereby certify that I attended the birth of the child who was born alive at ____________ oclock
am/pm on the date stated above.

81

Signature ______________________________
Name in Print __________________________
Title or Position __________________________

86

Address ______________________________
_____________________________________
Date _________________________________

87

20. INFORMANT

88
Signature ______________________________
Name in Print __________________________
Relationship to the child ___________________

Address ______________________________
_____________________________________
Date _________________________________

21. PREPARED BY

22. RECEIVED AT THE OFFICE


OF THE CIVIL REGISTRAR

Signature ______________________________
Name in Print __________________________
Title or Position __________________________
Date ___________________________________

Signature _____________________________
Name in Print _________________________
Title or Position _________________________
Date _________________________________

93

94

91

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. _________________


Date Issued ________________________
Place Issued ________________________

Community Tax No. _________________


Date Issued ________________________
Place Issued ________________________

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


at ________________________________________________________________________, Philippines.

___________________________________
(Signature of Administering Officer)

___________________________________
(Name in Print)

___________________________________
(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.)

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.
2.
3.
4.
5.

6.
7.
8.

That I am the applicant for the delayed registration of my birth/of the birth of
______________________________________.
That I/he/she was born on ______________________ at ______________________________.
That I/he/she was attended at birth by _________________________________ who resides at
_________________________________________________________________.
That I/he/she is a citizen of __________________________________________.
That my/his/her parents were
married on ________________________ at _____________
__________________________________________.
not married but was acknowledge by my/his/her father whose
name is __________________________________________.
That the reason for the delay in registering my/his/her birth was due to ________________________
____________________________________________________________________.
That a copy of my/his/her birth certificate is needed for the purpose of __________________________
______________________________________________________________.
(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)

___________________________________
(Name in Print)

___________________________________
(Title/designation)

___________________________________
(Address)

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