9048 10172 Form 1.1 CCE BC
9048 10172 Form 1.1 CCE BC
9048 10172 Form 1.1 CCE BC
1 (LCRO)
(Modified 7 January 2013)
5) The facts/reasons for filing this petition are the following: (Use additional sheet, if necessary)
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6) I submit the following documents to support this petition: (Use additional sheet if necessary)
a) _______________________________________________________________________________________
b) _______________________________________________________________________________________
c) _______________________________________________________________________________________
d) _______________________________________________________________________________________
e) _______________________________________________________________________________________
f) _______________________________________________________________________________________
g) _______________________________________________________________________________________
h) _______________________________________________________________________________________
7) I have/He/She has 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.
8) I am filing this petition at the CCRO of _____________________________, ___________________________
in accordance with R.A. No. 9048 / R.A. 10172 and its (city/municipality)
implementing rules and regulations. (province)
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Signature over printed name of petitioner
VERIFICATION
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Signature over printed name of petitioner
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Administering Officer
Doc. No.
Page No.
Book No.
Series of
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For C/MCR use only
ACTION TAKEN BY THE CCR
(Provide the basis for the action taken.)
Granted Denied
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Date: ______________________
City/Municipal Civil Registrar
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For CRG use only
ACTION TAKEN BY THE CRG
(Provide the basis for the action taken.)
Affirmed Impugned
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Date: _______________________
Civil Registrar General