Municipal Form 102 ≡ Fill Out Printable PDF Forms Online

Question	Answer
Form Name	Municipal Form 102
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	live birth form, municipal form no 102, birth certificate form, birth certificate sample

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Municipal Form No. 102	(To be accomplished in quadruplicate)
(Revised January 1993)
	Republic of the Philippines
	OFFICE OF THE CIVIL REGISTRAR GENERAL
	CERTIFICATE OF LIVE BIRTH

(Fill out completely, accurately and legibly. Use ink or typewriter. Place X before the appropriate ANSWER IN ITEMS 2, 5A, 5B AND 19A.)

	Province _________________________________________	Registry No.
	City/Municipality ___________________________________

REMARKS/ANNOTATION

NAME

(First)

(Middle)

(Last)

SEX

3. DATE OF BIRTH

(day) (month) (year)

______ 1 Male

_______ 2 Female

PLACE OF

(Name of Hospital/Clinic/Institution/

(City/Municipality)

(Province)

BIRTH

House No., Street, Barangay)

5a. TYPE OF BIRTH

b. IF MULTIPLE BIRTH, CHILD WAS

_____ 1 Single

______ 2

Twin

_____ 1

First

______ 2

Second

______ 3

Triplet. Etc.

______ 3

Others, Specify _____________

c. BIRTH ORDER (live births and fetal deaths

d. WEIGHT AT BIRTH

including this delivery)

_____________ (first, second, third, etc.)

________________ grams

MAIDEN

(First)

(Middle)

(Last)

NAME

CITIZENSHIP

RELIGION

9a.

c. No. of children

Total number of

No. of Children still

children born

living including

born alive but

alive: _________

this birth: _________

are now dead: _________

10. OCCUPATION

11. Age at the time

of this birth:

_______years

12.

RESIDENCE (House No., Street, Barangay)

(City/Municipality)

(Province)

13.

NAME

(First)

(Middle)

(Last)

14.

CITIZENSHIP

15. RELIGION

16.

OCCUPATION

17. Age at the time

of this birth:

_______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	______ 2 Nurse	______ 3 Midwife
_____4	Hilot (traditional Midwife)	______ 5 Others	(Specify)

_______________________________________________________________________________________________

19b. CERTIFICATION OF BIRTH

I hereby certify that I attended the birth of the child who was born alive at ______________o’clock

am/pm on the date stated above.
Signature ______________________________	Address ______________________________
Name in Print ___________________________	_____________________________________
Title or Position _________________________	Date _________________________________

_______________________________________________________________________________________________

20. INFORMANT

Signature ______________________________	Address ______________________________
Name in Print ___________________________	_____________________________________
Relationship to the child ___________________	Date ________________________________

_______________________________________________________________________________________________

21. PREPARED BY	22. RECEIVED AT THE OFFICE OF
	THE CIVIL REGISTRAR
Signature ______________________________	Signature _____________________________
Name in Print ___________________________	Name in Print __________________________
Title or Position _________________________	Title or Position ________________________
Date __________________________________	Date _________________________________
_______________________________________________________________________________________________

FOR OCRG USE ONLY:

Population reference No.

TO BE FILLED UP AT THE OFFICE OF THE CIVIL REGISTRAR

4950

62	64


68	69


70	72	74

7679

86 87

8891

For this before 3 August 1988/on or after 3 August 1998

AFFIDAVIT OF ACKNOWLEDGEMENT/ADMISSION OF PATERNITY

Well, ___________________________________________________ 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 best of our/my knowledge and belief.
_________________________________	_______________________________
(Signature of Father)	(Signature of Mother)
Community Tax No. _______________________	Community Tax No. _____________________
Date Issued _______________________________	Date Issued ____________________________
Place Issued ______________________________	Place Issued ____________________________

SUBSCRIBED AND SWORN to before me this ___________ day of ____________________________, _________________

at ___________________________________________________________________________________, Philippines.

_________________________________________	_______________________________________
(Signature of Administering Officer)	(Title/Designation)
_______________________________________________	___________________________________________
(Name in Print)	(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.That I am the applicant for the delayed registration of my birth/of the birth of

_______________________________________________________.

2.That I/he/she was born on ____________________ at _____________________________________________.

3.That I/he/she was attended at birth by _______________________________________________who resides at

_____________________________________________________________________________.

4.That I/he/she is citizen of _________________________________________________________.

5. That my/his/her parents were		married on ____________________ at _______________________
		_______________________________________________.
		_______________________________________________.
		not married but was acknowledge by my/his/her father whose
		not married but was acknowledge by my/his/her father whose
		name is ________________________________________________.
		name is ________________________________________________.

6.That the reason for the delay in registering my/his/her birth was due to ________________________________

________________________________________________________________.

7.That a copy of my/his/her birth certificate is needed for the purpose of ________________________________

	________________________________________________________________.
8.	(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)	(Title/Designation)
_________________________________________________	______________________________________________
(Name in Print)	(Address)

Municipal Form 102 – Fill Out and Use

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