RA 9048 Form No. 4.

1(LCRO)
Republic of the Philippines
Local Civil Registry Office
Province: _________________________
City/Municipality: ___________________________
Republic of the Philippines
_______________________

)
) S.S.

Petition No. __________________

PETITION FOR CHANGE OF FIRST NAME

I, ______________________________________, of legal age, _________________________
(Complete name of petitioner)

(Nationality/citizenship)

and a resident of ____________________________________________________________________

after having been duly sworn to in accordance with law, hereby declare that:
1.) I am the petitioner seeking the change of first name in:
a) my Certificate of Live Birth
b) the Certificate of Live Birth of ___________________________________________
(complete name of owner)

who is my ________________________________________________________________
(relation

of owner to the petitioner)

2.) I/He/She was born on _____________________________ at ______________________________,

(date of birth)

(city/municipal)

______________________________________________, ________________________________.
(province)

(country)

3.) The birth was recorded under registry number __________________________________________.

4.) The first name to be change is from __________________________ to ______________________.
5.) The ground for filing this form petition are the following: (Ground selected should be explained/justified in
a separate sheet of paper to be attached to this form.)
a)

The first name is extremely difficult to write or pronounce.

b)

I have/He/She has habitually and continuously used ______________________

and I/He/She is publicly known in the community with that first name.

c)

The first name is tainted with dishonor;

d)

The first name is ridiculous;

e)

The present first name causes confusion;

6.) I submit the following documents to support this petition: (Use additional sheets if necessary.)
a)
b)
c)
d)

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

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 have/He/She has no pending criminal, civil or administrative case in any court or any quasijudicial body.
9.) I am filing this petition at the LCRO of __________________________, _____________________
(city/municipality)

in accordance with R.A. No. 9048 and its implementing rules and regulations.

(province)

Page 2

_____________________________________
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

SUBCRIBED AND SWORN to before me this ____________ day of __________________________ in

The City/Municipality of ________________________ petitioner exhibiting his Community Tax
Certificate No. ___________________ issued at __________________ on _____________________.

____________________________
Administering Officer
Doc. No.
Page No.
Book No.
Series No.

_____________
_____________
_____________
_____________

For C/MCR use only

ACTION TAKEN BY THE C/MCR
(Provide the basis for the action taken.)
Granted

Denied

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Date: __________________

__________________________________

City/Municipal Civil Registry

For CRG use only

ACTION TAKEN BY THE CRG
(Provide the basis for the action taken.)
Affirmed

Impugned

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Date: __________________

__________________________________

City Registry General

Payment of filing fee (Please attach copy of the official recipe.)
O.R. No.
____________
Amount paid ____________
Date paid
____________