(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,
singles/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 / or 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 a citizen of _________________________________________;
5. That my / his / her parents were ________________________________________
( ) married on _____________________ at _______________________________
( ) not married but was acknowledged by my / his / her father whose 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.
________________________________
(Affiant signature over printed name)
SUBSCRIBED AND SWORN to before me this _____________________ day of
______________________, 20 __ in the City and County of Los Angeles,
California, U.S.A.
name of doctor/nurse/hilot
address of hospital/hilot
indicate parents' full names
place where you signed affidavit
