Republic of the Philippines

LOCAL CIVIL REGISTRAR

Bulacan
CITY OF SAN JOSE DEL MONTE

Republic of the Philippines )

Province of Bulacan ) Petition No. _______
City of San Jose del Monte ) SS

PETITION FOR CHANGE OF NAME

I, (name of petitioner), of legal age, Filipino and a resident of

___________________________ after having been duly sworn to in accordance with
law, hereby declare that:

1. I am the petitioner seeking the removal of middle name in the Certificate of Live Birth
of Jerone M. Cillano, who is my nephew.

2. He was born on July 16, 1993 at _______________________.

3. The birth was recorded under registry number ___________________

4. The grounds for filing this petition are the following: (ground selected should be
explained in a separate sheet of paper to be attached to this form.)

a) The first name is extremely difficult to write or pronounce;

b) He is habitually and continuously used ______________and is publicly known in
the community known with that first name;
c) The first name is ridiculous;
d) The first name is ridiculous;
e) The first name causes confusion;

6. I submit the following documents to support this petition: (Use additional sheet, if
necessary.)
a) ____________________
b) ____________________
c) ____________________
d) ____________________

7. I have not filed and similar petition and that, to the best of my knowledge, no longer
similar petition is pending with any LCRO, Court or Philippine Consulate.

8. I am filing this petition at the LCRO of __________________, _______________ in

accordance with RA 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 of __________________, petitioner exhibiting his Community Tax Certificate No.
_________________ issued at _______________ on _____________.

Doc. No. ___________________

Page No. ___________________ _______________________
Book No. __________________ Administering Officer
Series of ________