REPUBLIC OF THE PHILIPPINES

National Capital Judicial region

REGIONAL TRIAL COURT
Branch ___, _____ City

In the matter of change

of name from MARA
to CLARA by reason of
marriage to _______________
Sp. Proc. No. _____________
DANA BULAON,
Petitioner,

-versus-

THE LOCAL CIVIL REGISTRAR OF

_____________ and the PHILIPPINE
STATISTICS OFFICE ,

Respondent,
x----------------------------------------------------------x

PETITION
Petitioner, MARA, years of age, married, Filipino, and a resident of
_________________________, through the undersigned counsel and unto this
Honorable Court, respectfully avers that:

1. Petitioner is married to ________, an Canadian National with residence

at ________________.
2. Respondents are government entities whose functions include the
custody of birth records as well as registration thereof. Respondent is holding office at
Philippines where summons and other court processes can be served;

3. Petitioner was born on ______________ in ___________ and duly

recorded in the Local Civil Registry of ______________ as evidenced by the
Certificate of Birth issued by the Local Civil Registrar of Pasig, herein attached as
Annex “A”;

4. Petitioner has made herself known to the public for the past _______
years and continues to do so as __________, as shown by her school diploma.
Attached herein and made integral part of this Petition is his ___________ issued by
_________________ marked as Annex “B”;

5. Last ________, Petitioner married ___________ at _____________ .

6. Due to this marriage,

 7. After the discovery of the erroneous entries in his birth record,
Petitioner secured a birth certificate from the Carmen Civil Registrar’s Office and the
same errors were discovered;

8. Petitioner ahs no derogatory record in his character as evidenced by the

clearances issued by the proper authorities herein attached as Annex “D”, “E”, “F”,
“G”, “H”, and “I”, respectively;

PRAYER

WHEREFORE, it most respectfully prayed that, after the due notice and
publication, and hearing, this Honorable Court adjudge and order herein Respondent
to effect the rectification of the Birth Record of MARA pertaining to the entries in
the surname of the child from MARA to CLARA..

Other reliefs just and equitable under the circumstances are likewise prayed for.

RESPECTFULLY SUBMITTED.

August 4, 2014. Pasig City, Philippines.

DEPARTMENT OF JUSTICE
PUBLIC ATTORNEY’S OFFICE
Danao City District Office
COUNSEL FOR PETITIONER
By:

ATTY. JOSE FERNANDO

Public Attorney II
Attorney’s Roll No. 11111
IBP No. 1111, 02.28.14, Cebu
MCLE Compliance No. III-11111/03.24.14
REPUBLIC OF THE PHILIPPINES}
}SS

VERIFICATION and CERTIFICATION

OF NON-FORUM SHOPPING
___________________________________

I, MARA, after being sworn to in accordance with law, deposes and states:

1. That, I am the Petitioner in the above-entitled case;

2. That, I have caused the Petition to be prepared and has read the
contents thereof;

3. That, the allegations therein are true and correct of own knowledge and
authentic documents;

4. That, I have not therefore commenced any other action or proceeding

involving the same issues in the Supreme Court, the Court of Appeals, or any other
tribunal, agency or hearing officer, to the best of my knowledge, no such action or
proceeding is pending in the Supreme Court, the Court of Appeals, or any other
tribunal, agency or hearing officer; if I should learn thereafter that a similar action or
proceeding has been filed or pending, I shall undertake to report such fact within five
(5) days therefrom to this Honorable Court.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my

signature this ___ April 2019 in _____City, Philippines.

MARA
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this __ April 2019 in

_________ City, Philippines. Affiant appeared and exhibited her ________________
issued on ________ in ________.

NOTARY PUBLIC
Copy furnished via registered mail:

THE SOLICITOR GENERAL

Office of the Solicitor General
134 Amorsolo St., Legaspi Village
Makati City, Philippines

THE LOCAL CIVIL REGISTRAR OF _______

City Hall Compound, Poblacion
Pasig City

MS. CARMELITA N. ERICTA

National Statistics Office
3/F Vibal Building, corner Times Street
Quezon City