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)