RA 9048 Form No. 1.2 (Philippine Consulate General, NY)
(Revised 30 Sept. 2010)
Republic of the Philippines
Philippine
Consulate- Consular
General Section
Embassy of the Philippines
LOS
ANGELES,
CALIFORNIA
New
York, New
York
Washington,
D.C.
_______________________________)
_______________________________) SS
Petition No. ______________________
PETITION FOR CORRECTION OF CLERICAL ERROR
IN THE CERTIFICATE OF LIVE BIRTH
I, _______________________________________________________, of legal age, _________,
and a resident of _____________________________________________________________________,
(complete address)
after having duly sworn to in accordance with law, hereby declare that:
1)
I am the petitioner seeking correction of the clerical error in:
a. [ ] my Certificate of Live Birth
b. [ ] the Certificate of Live Birth of ___________________________________________
(complete name of owner)
who is my ____________________________________________.
(relation of owner to the petitioner)
2)
I/He/She was born on __________________ at ______________________________________,
(city/ municipality)
______________________________________________, _____________________________________.
(province)
(country)
3)
The birth was recorded under registry number ________________________________________.
4)
The clerical error(s) to be corrected is (are):
Item No.
5)
Description
From
To
The facts/reasons for filing this petition are the following: (Use additional sheets, if necessary)
For error No. 1:
___________________________________________________________
___________________________________________________________
___________________________________________________________
For error No. 2:
___________________________________________________________
___________________________________________________________
___________________________________________________________
For error No. 3:
___________________________________________________________
___________________________________________________________
___________________________________________________________
6)
7)
I submit the following documents to support this petition: (Use additional sheets, if necessary)
a.
________________________________________________________________
b.
________________________________________________________________
c.
________________________________________________________________
d.
________________________________________________________________
e.
________________________________________________________________
I have/He/She has not filed any similar petition and that, to the best of my knowledge, no other
similar petition is pending with any LCRO, Court or Philippine Consulate.
8)
Officeof
of Consulate
the Consul
General
Washington,
D.C.,
I am filing this petition at the Philippine
Office
the
Consul
General
of
Philippine
Consulate
of New
General
in in
Los
Angeles,
California
USA General
in
accordance with RA 9048 as amended and its Implementing Rules and Regulations.
York, New York, USA in accordance with R.A. 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 Passport
No. _______________ issued at _____________________________ on ________________________.
_____________________________________________
Administering Officer
Doc. No.
________________________
Page No.
________________________
Book No.
________________________
Series of
________________________
ACTION TAKEN BY THE CONSUL GENERAL ON ERROR NO. 1
(Provide the basis for the action taken.)
[ ] Granted
[ ] Denied
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
ACTION TAKEN BY THE CONSUL GENERAL ON ERROR NO. 2
(Provide the basis for the action taken.)
[ ] Granted
[ ] Denied
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
ACTION TAKEN BY THE CONSUL GENERAL ON ERROR NO. 3
(Provide the basis for the action taken.)
[ ] Granted
[ ] Denied
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
___________________________________
Consul General
Date: _________________________
For CRG use only:
ACTION TAKEN BY CRG ON ERROR NO. 1
(Provide the basis for the action taken.)
[ ] Affirmed
[ ] Impugned
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
For CRG use only:
ACTION TAKEN BY CRG ON ERROR NO. 2
(Provide the basis for the action taken.)
[ ] Affirmed
[ ] Impugned
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
For CRG use only:
ACTION TAKEN BY CRG ON ERROR NO. 3
(Provide the basis for the action taken.)
[ ] Affirmed
[ ] Impugned
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Date: ___________________________
______________________________________
Civil Registrar General
Payment of filing fee (Please attach copy of the official receipt.)
O.R. No.
___________________________
Amount paid
___________________________
Date paid
___________________________