R. A. 9048 Form No. 4.
1 (LCRO)
Republic of the Philippines
CITY CIVIL REGISTRAR’S OFFICE
City of Davao
Republic of the Philippines} Petition No. _______________
City of Davao……………..}SS.
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I, (Petitioner), of legal age, Filipino, single, and a resident of
_________________________, under oath, do hereby depose and state that:
1. I am the attorneyinfact of Mrs. ____(parent)______ by virtue of a
Special Power of Attorney as appearing in the notarial books of
Notary Public ________________ under notarial entries Doc. No.
100; Page No. 20; Book No. CCXXXI; Series of __________, for
purposes of, among others, processing and facilitating the petition for
change of name of her son, _____(child)_____, and such all other
requirements and papers with all government offices that are
necessary and desirable to change the said name of her son;
2. I am the petitioner seeking the change of First Name of the Certificate
of Live Birth of _____(child)_____, who is the son of my principal,
Mrs. __________(parent)_________;
3. ____(Child)______ was born on _____________ and registered at
Cagayan de Oro, Misamis Oriental, Philippines;
4. The birth was registered under Registry No. ___________ at the
Local Civil Registrar of Cagayan de Oro City;
5. The first name to be changed is from “Mikki” to “Mikki Mousu”;
6. The ground for filing this petition is that He has habitually and
continuously used “Mikki Mousu” and he is publicly known in the
community with that first name;
7. I submit the following documents to support this petition:
a. Secondary Permanent Record issued by _________________;
b. Baptismal Certificate as issued on ____________ of the
Archdiocese of Cagayan de Oro;
c. School Identification Card;
d. National Bureau of Investigation Clearance issued on February 5,
2013;
e. Police Clearance;
f. Community Tax Certificate issued on February 4, 2013 at Davao
City;
g. Barangay Certification issued on February 4, 2013 at Buhangin
District, Davao City;
8. He 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;
9. He has no pending criminal, civil or administrative case as in any
court or any quasijudicial body;
10.I am filing this petition at the LCRO of Cagayan de Oro, Misamis
Oriental, in accordance with R.A. No. 9048 and its implementing
rules and regulations.
Atty. ______________
Petitioner
VERIFICATION
I, ________________, the petitioner, hereby certify that the
allegations herein are true and correct to the best of my knowledge and
belief.
Atty. __________________
Petitioner
SUBSCRIBED AND SWORN to before me this 6th day of February,
2013 at Davao City, Philippines, with the petitioner exhibiting his
Taxpayer’s Identification Card with No. _______________ issued on 0618
2010.
Doc. No. _____;
Page No. _____;
Book No. ____;
Series of 2013.
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For C/MCR use only
ACTION TAKEN BY C/MCR
(Provide basis for the action taken.)
□ Granted □ Denied
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Date ________________ ATTY. LEO ANTHONY R. BRACEROS
City/Municipal Civil Registrar
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For CRG use only
ACTION TAKEN BY CRG
(Provide basis for the action taken.)
□
Granted Denied □
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Date ________________ _______________________
Civil Registrar General
Payment of filing fee (Please attach copy of the official receipt.)
O.R. No. ____________
Amount Paid ____________
Date Paid ____________
