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PHILIPPINE CONSULATE GENERAL LOS ANGELES SUPPLEMENTAL REPORT AND (Philippine Consulate General Los Angeles California)

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PHILIPPINE CONSULATE GENERAL LOS ANGELES
SUPPLEMENTAL REPORT AND AFFIDAVIT OF EXPLANATION FOR REPORT OF DEATH
1. Full Name of Deceased
2. Registry Number
3. Date Deceased Died
4. Information Omitted
(If there is only one omitted entry write “
N/A” for the blanks in item no. 4b.
For more than 2 omitted entries, use a
separate sheet and all files will be forwarded
to the Civil Registrar General in the
Philippines for approval)
4a.
4b.
5. Name of Informant
6. Relationship to Deceased
7. Date Received by
Civil Registry Section
AFFIDAVIT of EXPLANATION
(Write “N/A” for inapplicable items)
I, ______________________________ of legal age, ______________, ___________, presently residing at
(full name) (civil status) (citizenship)
_________________________________________, after having been sworn to in accordance with law, hereby state:
(home address)
1. That _____________________________________________________________________, died on
(full name)
___________________________________ at
____________________________________, USA;
(date )
(place)
2. That the Report of Death was registered with the Philippine Consulate General in Los Angeles, California
under Registry Number ______________________;
3. That the information _____________________________________________ under item no. ___________
(item omitted) (item no.)
was omitted because ____________________________________________________________________________;
(reason)
4. That the information ___________________________________________ under item no. ___________
(item omitted) (item no.)
was omitted because ____________________________________________________________________________;
(reason)
(If there is only one omitted entry write “ N/A” for the blanks in item no. 4. For more than 2 omitted entries, use a separate
sheet and all files will be forwarded to the Civil Registrar General in the Philippines for approval)
5. That I am executing this affidavit to attest the truth and veracity of the foregoing statements for legal
intents and purposes.
(Last Name, First Name, Middle Name)
(MONTH - DAY - YEAR)
(Last Name, First Name, Middle Name)
FURTHER AFFIANT SAYETH NAUGHT.
IN WITNESS WHEREOF, I hereby affixed my signature on _____________________________________
(date signed )
at ______________________________________________________________________________________, USA;
(place of signed)
__________________________________
Affiant
(Printed Name over Signature)
SUBSCRIBED AND SWORN to before me on ___________________ at __________________________, affiant
exhibiting to me his/her ____________________ issued on ________________________________ in
_______________________.
NOTARY PUBLIC
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Completed 6 June 2021

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