Report Of Birth Form - Republic Of The Philippines Department Of Foreign Affairs

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NOT FOR SALE

REPUBLIC OF THE PHILIPPINES

FA FORM NO.40

DEPARTMENT OF FOREIGN AFFAIRS

(REVISED JUNE 2013)

REPORT OF BIRTH

DATE OF REPORT

(day-month-year)

CHILD BORN ABROAD OF FILIPINO PARENT/S

THIS FORM IS NOT FOR SALE. DO NOT LEAVE ANY SPACES BLANK. INDICATE N/A IF NOT APPLICABLE.

Foreign Service Post: TOKYO, JAPAN

DETAILS OF CHILD’S BIRTH

1. CHILD’S LAST NAME

5. DATE OF BIRTH

(day-month-year)

2. CHILD’S FIRST NAME

6. TIME OF BIRTH

(

) AM

(

) PM

3. CHILD’S MIDDLE NAME

7. SEX :

(

) MALE

(

) FEMALE

4. PLACE OF BIRTH

8. CIVIL STATUS OF PARENTS: (

) MARRIED (

) NOT MARRIED

DETAILS OF BIRTH PARENTS (at the time of child’s birth)

INFORMATION ON BIRTH FATHER

INFORMATION ON BIRTH MOTHER

9. LAST NAME

10. FIRST NAME

11. MIDDLE NAME

12. NAME BEFORE MARRIAGE

13. CITIZENSHIP

14. DATE OF BIRTH

(day-month-year)

15. PLACE OF BIRTH

16. OCCUPATION

17. RELIGION

18. HOME ADDRESS

19. NATURALIZED

(IF FOREIGN BORN)

20. DATE AND PLACE OF REGISTRATION

AS PHILIPPINE CITIZEN

(day-month-year/country)

21. DATE OF MARRIAGE

24. PLACE OF MARRIAGE

(day-month-year)

22. NUMBER OF PREVIOUS CHILDREN

25. NUMBER OF CHILDREN NOW LIVING

23. SIGNATURE OF PARENT, PHYSICIAN OR NURSE OVER PRINTED NAME

WHEN REPORTED BY MAIL, USE THIS PORTION IN THE PRESENCE OF TWO WITNESSES:

WHEN REPORTED IN PERSON, USE THIS PORTION:

Declared in our presence this _______ day of ___________ at _______________________.

Subscribed and sworn to before me this _______ day of _____________

First Witness: ______________________________________________________________

at the Embassy of the Philippines in Tokyo, Japan.

Address: __________________________________________________________________

Second Witness: ____________________________________________________________

Address: __________________________________________________________________

SEAL

REPUBLIC OF THE PHILIPPINES

EMBASSY OF THE REPUBLIC OF THE PHILIPPINES

The foregoing information was furnished by (father, mother, physician, nurse) and supported by (affidavit, physician’s certificate, certificate from local authorities).

This report has been executed in quadruplicate, copy issued to parents, copy transmitted to the Department of Foreign Affairs (DFA) in Manila, copy transmitted to the

Civil Registrar General through the DFA and copy placed in the files of this Office.

Date:

_________________________

Doc. No.

_________________________

Service No. _________________________

O.R. No.

_________________________

Fee Paid:

_________________________

Book No.

_________________________