Republic of the Philippines
Municipality of ______ Barangay
BARANGAY _________ Logo
OFFICE OF THE PUNONG BARANGAY
CERTIFICATION
Control No.: _________
TO WHOM IT MAY CONCERN:
This is to certify that the person whose name, photo, signature/thumbmark
appears herein is a bonafide resident of ________________
FULL NAME: ______________________________________
SEX: __________
DATE OF BIRTH: _____________________________
PLACE OF BIRTH: _____________________________
ADDRESS: ______________________________
FULL NAME OF FATHER: ________________________________
MAIDEN NAME OF MOTHER: ____________________________
This certification is issued upon the request of the above-mentioned name for the purpose of delayed
registration of birth.
______________________________________
Name and Signature/Thumbmark of the Applicant
_____________________________________
Name and Signature of the Punong Barangay