Fill - Free fillable RA 9048 Form No. 3.2 (Philippine Consulate General, (Philippine Consulate General Los Angeles California) PDF form

RA 9048 Form No. 3.2 (Philippine Consulate General, NY)

(Revised 30 Sept. 2010)

Republic of the Philippines

Philippine Consulate General

New York, New York

_______________________________)

_______________________________) SS Petition No. ______________________

PETITION FOR CORRECTION OF CLERICAL ERROR

IN THE CERTIFICATE OF DEATH

I, _______________________________________________________, of legal age, _________,

and a resident of _____________________________________________________________________,

(complete address)

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

1) I am the petitioner seeking correction of the clerical error in THE Certificate of Death of

_________________________________________ who is my ___________________________.

(complete name of deceased)

(relation of owner to the petitioner)

2) He/She died on __________________ at ______________________________________,

(date of death) (city/ municipality)

______________________________________________, _____________________________________.

(province) (country)

3) The death was recorded under registry number _______________________________________.

4) The clerical error(s) to be corrected is (are):

Item No.

Description

From

5) The facts/reasons for filing this petition are the following: (Use additional sheets, if necessary)

For error No. 1: ___________________________________________________________

___________________________________________________________

For error No. 2: ___________________________________________________________

___________________________________________________________

For error No. 3: ___________________________________________________________

___________________________________________________________

6) I submit the following documents to support this petition: (Use additional sheets, if necessary)

a. ________________________________________________________________

b. ________________________________________________________________

c. ________________________________________________________________

d. ________________________________________________________________

e. ________________________________________________________________

7) I have 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.

LOS ANGELES, CALIFORNIA

8) I am filing this petition at the Office of the Consul General of Philippine Consulate General of New

York, New York, USA in accordance with R.A. 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/ municipality of ____________________________________, petitioner exhibiting his Passport

No. _______________ issued at _____________________________ on ________________________.

_____________________________________________

Administering Officer

Doc. No. ________________________

Page No. ________________________

Book No. ________________________

Series of ________________________

ACTION TAKEN BY THE CONSUL GENERAL ON ERROR NO. 1

(Provide the basis for the action taken.)

[ ] Granted [ ] Denied

____________________________________________________________________________

ACTION TAKEN BY THE CONSUL GENERAL ON ERROR NO. 2

(Provide the basis for the action taken.)

[ ] Granted [ ] Denied

____________________________________________________________________________

Philippine Consulate General in Los Angeles, CaliforniaPhilippine Consulate General in Los Angeles, Califonia USA in

accordance with RA 9048 as amended and its Implementing Rules and Regulations

ACTION TAKEN BY THE CONSUL GENERAL ON ERROR NO. 3

(Provide the basis for the action taken.)

[ ] Granted [ ] Denied

____________________________________________________________________________

___________________________________

Consul General

Date: _________________________

For CRG use only:

ACTION TAKEN BY CRG ON ERROR NO. 1

(Provide the basis for the action taken.)

[ ] Affirmed [ ] Impugned

____________________________________________________________________________

For CRG use only:

ACTION TAKEN BY CRG ON ERROR NO. 2

(Provide the basis for the action taken.)

[ ] Affirmed [ ] Impugned

____________________________________________________________________________

For CRG use only:

ACTION TAKEN BY CRG ON ERROR NO. 3

(Provide the basis for the action taken.)

[ ] Affirmed [ ] Impugned

____________________________________________________________________________

Date: ___________________________ ______________________________________

Civil Registrar General

Payment of filing fee (Please attach copy of the official receipt.)

O.R. No. ___________________________

Amount paid ___________________________

Date paid ___________________________

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RA 9048 Form No. 3.2 (Philippine Consulate General, (Philippine Consulate General Los Angeles California)

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