RA 9048 Form No. 1.1.
(LCRO)
(Devised 15 Aug. 2001)
REPUBLIC OF THE PHILIPPINES
LOCAL CIVIL REGISTRY OFFICE
Province of _____________
CITY OF ______________
Republic of the Philippines )
Province of ___________ )
City of _______ ) S.S.
Petition No. ______________
PETITION FOR CORRECTION OF CLERICAL ERROR
IN THE CERTIFICATE OF LIVE BIRTH
I,_____________(complete name of petitioner)_______________________,
of legal age, ______(Nationality/Citizenship)_______________and a resident of
________(complete address)_______________________________ after having
been duly sworn to in accordance with law, hereby declare that:
1. I am a petitioner seeking correction of the clerical error in:
a) my Certificate of Live Birth;
b) the Certificate of Live of _____(complete name of owner)__________ who
is my ___________(relationship of owner to the petitioner)________;
2. I/He/She was born on ______________________ at ____________________,
__________(province)__________, ____(country)___________________;
3. The birth was recorded under registry number __________________________;
4. The clerical error(s) to be corrected is (are):(Use additional sheets, if necessary.)
Item No.
Description
From
To
5. The facts/reasons for filling this petition are the following:
(Use additional sheets, if necessary.)
___________________________________________________________________
_________
___________________________________________________________________
_________
___________________________________________________________________
_________
___________________________________________________________________
_________
___________________________________________________________________
_________
6. I submit the following documents to support this petition:
(Use additional sheets, if necessary.)
a)
___________________________________________________________________
_____
b)
___________________________________________________________________
_____
c)
___________________________________________________________________
_____
d)
___________________________________________________________________
_____
7. I have not filed and similar petition and that, to the best of my knowledge, no
longer similar
petition is pending with any LCRO, Court or Philippine Consulate.
8.
I am filing this petition at the LCRO of ______________________,
_______________________
(city/municipality) (province)
in accordance with RA No. 9048 and its implementing rules and regulations.
__________________________________
Signature over printed name of petitioner
VERIFICATION
I, ____________________________________, the petitioner, hereby certify that the
allegations
herein are true and correct to the best of my knowledge and belief.
______________________________
Signature over printed name of petitioner
SUBSCRIBED AND SWORN to before me this ___________ day of
_____________________
in the city / municipality of _____________________________,
petitioner exhibiting his Community Tax
Certificate No. __________________ issued at __________________ on
______________________.
Doc. No. ________________
Page. No. ________________
__________________________
Book No. ________________
Administering Officer
Series of ________________
For
C/MCR
use only
ACTION TAKEN
BY THE C/MCR
Granted
Denied
(Provide the basis for denial.)
___________________________________________________________________
_______________
___________________________________________________________________
_______________
___________________________________________________________________
_______________
___________________________________________________________________
_______________
___________________________________________________________________
_______________
___________________________________________________________________
_______________
Date: _____________________
_____________________________
City / Municipal Civil Registrar
For
CRG
use only
ACTION TAKEN BY THE CRG
Affirmed Impugned
___________________________________________________________________
_______________
___________________________________________________________________
_______________
___________________________________________________________________
_______________
___________________________________________________________________
_______________
___________________________________________________________________
_______________
___________________________________________________________________
_______________
Date: ____________________________
___________________________
Civil Registrar General
Payment of filing fee
(Please attach copy of the official receipt.)
O.R. No.
________________
Amount Paid ________________
Date paid
________________
