DFA Form No

DFA Form No. 40

(Est. April; 1947)

FOREIGN SERVICE OF THE PHILIPPINES

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REPORT OF BIRTH

CHILD BORN ABROAD OF PHILIPPINE PARENT OR PARENTS

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(Place and date of report)

Name of Child (in full): ______Sex: ______

Date of Birth: ______20 _____ Hour : ______Minutes : ______

Place of Birth (in full): ______

Civil status of parents: ______

FATHER MOTHER

Full Name: ______Full Name: ______

Race: ______; Religion: ______Name before marriage: ______

Date of Birth: ______Race: ______; Religion: ______

Occupation: ______Date of Birth: ______

Present residence: ______Present residence: ______

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Birthplace: ______Birthplace: ______

Naturalized (if foreign born): ______Naturalized (if foreign born): ______

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Registered as Philippine Citizen at : ______Registered as Philippine citizen at : ______

______on: ______on: ______

Passport No. : ______Passport No.: ______

issued by: ______issued by: ______

dated: ______valid to: ______dated: ______valid to: ______

Precise periods and places of Philippine residence: _ Precise periods and places of Philippine res.: _

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Place and date of Marriage: ______

Number of previous children: ______Number now living: ______

Name and address of physician or nurse: ______

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(Signature of parent, physician or nurse)

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(WHEN REPORTED BY MAIL, SIGN IN THE

PRESENCE OF TWO WITNESSES

Declared in our presence this ______

day of ______at ____

(Witness) ______

(Address) ______

(Seal)

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PHILIPPINE EMBASSY

At ______

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The foregoing information was furnished by (father, mother, physician, nurse) and supported by (affidavit, physician’s certificate from local authorities). This report has been executed in triplicate, copy issued to parents, copy transmitted to Department of Foreign Affairs, Manila, and copy placed in the files of this Office.

REMARKS ______

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(SEAL) ______No fee prescribed ______of the Philippines

(October 1955-2,000)

019287 (OVER)

AFFIDAVIT OF ACKNOWLEDGMENT / 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 best of our / my knowledge and belief.

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Signature of Father Signature of Mother

Passport No.: ______Passport No.:______

Date Issued : ______Date Issued :______

Place Issued : ______Place Issued: ______

SUBSCRIBED AND SWORN to before me this ____day of ______, ______at Seoul, Republic of Korea.

NOTE

The Foreign Service Officer by whom this report of birth is prepared should notify the Philippine mother, or, if that is impracticable, the alien parent, that under the provisions of the Constitution, the Child , whose birth is reported herein, of a Filipino mother will be considered as in possession of Philippine citizenship only if he or she elects such citizenship at the age of majority.

Such notification was communicated orally / by mail on ______to ______with address at ______

BABY’S FOOTPRINTS

LEFT RIGHT

Date: ______

WITNESSES :

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Signature over Printed Name Signature over Printed Name