AnnexDApplicationforChange Correction of Entries Inclusion of Record in the Book of Voters and Reinstatement of Name in the List of Voter Update

8/12/2019 AnnexDApplicationforChange Correction of Entries Inclusion of Record in the Book of Voters and Reinstatement of

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f \ R e p u b l i c of the P h i l i p p i n e s

C O M M I S S I O N O N E L E C T I O N S

CEF-1D

A P P L I C A T I O N F O R C H A N G E / C O R R E C T I O N O F E N T R I E S /I N C L U S I O N O F R E C O R D I N T H E B O O K O F V O T E R S A N D

R E I N S T A T E M E N T O F N A M E I N T H E L I S T O F V O T E R S .

A P P L I C A T I O N F O R C H A N G E / C O R R E C T I O N O F E N T R I E S

C h a n g e o f n a m e b y r e a s o n o f m a r r i a g e |~ 1 C o r r e c t i o n o f w r o n g o r m i s s p e l l e dor b y v i r t u e o f a c o u r t o r d e r | | n a m e i n t h e l i s t o f v o t e r s

T H E E L E C T I O N R E G I S T R A T I O N B O A R D

C i t y / M u n i c i p a l i t y o fP r o v i n c e o f

C o r r e c t i o n o f a n yo t h e r e n t r yT h r o u g h : T h e El e c t i o n O f f i c e r

D e a r S i r / M a d a m :

IFirst name/Middle name/Last name

a d u l y r e g i s t e r e d v o te r , d o h e r e b y r e q u e s t th a t m y

, F i li p i n o , b o r n o nmonth/day/year

a s r e c o r d e d i n t h e l i s tinformation t o be changed o r corrected)

fo r P r e c i n c t No. , w i t h a d d r e s s a t( S i t i o , B a r a n g a y, M u n i c i p a l i t y )

t o .e c h a n g e d f r o mPresent da ta) Ne w da ta)

T h a t s a i d c h a n g e / c o r r e c t i o n i s n e c e s s a r y a n d v a l i d a s e v i d e n c e d b y t h e a t t a c h e d c e r t i f i c a t i on / o r d e r o ft h e c o u r t .

U J

2zuUJXr -

tt

Ou.

a .Ou

( S i g n a t u r e a b o v e P r i n te d N a m e )

S U B S C R I B E D A N D S W O R N t o b e f o r e m e o n t h e a b o v e d a t e .

E O / C h a i r m a n o f t h e E l e c t i o n R e g i s t r a t i o n B o a r d( S i g n a t u r e a b o v e P r i n t e d N a m e )

A P P L I C A T I O N F O R I N C L U S I O N O F R E C O R D S I N T H E B O O K O F V O T E R S / R E I N S T A T E M E N T

O F N A M E I N T H E L I S T O F V O T E R S

I n c l u s i o n o f VRR in the p r e c i n c t b o o k o fv o t e r s R e i n s t a t e m e n t o f r e g i s t e r e d v o t e r w h o s en a m e ha s b e e n o m i t t e d i n t h e l i s t o f v o t e r sT H E E L E C T I O N R E G I S T R A T I O N B O A R D

C i t y / M u n i c i p a l i t y o fP r o v i n c e o f

T h r o u g h : T h e E l e c t i o n O f f i c e r

D e a r S i r / M a d a m :

I _, F i l i p i n o , b o r n o nFirst name/Middle nam e/Last name month/day/year

w i t h a d d r e s s a t ,

a d u l y r e g i s t e r e d v o te r , d o h e r e b y r e q u e s t t h a t m y n a m e w h i c h h a s b e e n o m i t t e d i n t h e l i s t o f v o t e r s / m y

r e g i s t r a t i o n r e c o r d w h i c h h a s n o t b e e n i n c l u d e d i n t h e p r e c i n c t b o o k o f v o t e r s o f P r e c i n c t n o . ,

b e r e i n s t a t e d / i n c l u d e d t h e r e i n .

T h e s a i d r e i n s t a t e m e n t o f n a m e / i n c l u s i on o f r e g i s t r a t i o n r e c o r d i s n e c e s s a r y a n d v a l i d .

( S i g n a t u r e a b o v e P r i n te d N a m e )

S U B S C R I B E D A N D S W O R N t o b e f o r e m e o n t h e a b o v e d a t e .

E O / C h a i r m a n o f t h e E l e c t i o n R e g i s t r a t i o n B o a r d( S i g n a t u r e a b o v e P r i n t e d N a m e )

N o t i c e to t h e a p p l i c a n t : I f yo u r b i o m e t r i c s , i .e. p h o t o g r a p h , s i g n a t u r e a n d f i n g e r p r i n t s h a d n o t b e e n c a p t u r e d d i g i t a l l y, p l e a s e a c c o m p l i s ht h e f o r m a t t h e b a c k .

Download ed From: http://www.comelec.gov.ph


2/6

A p p l i c a t i o n N o .

I * I 1 1 1 I I \ I I- I I

P r e c i n c N o ,

I n s t r u c t i o n s : ( 1 ) Accomplish s e p a r a t e l y in t h r e e copies ( 2 ) p r i n t l e g i b l y ; ( 3 ) check th e a p p r o p r i a t e box. -"

P A R T 1 P E R S O N A L I N F O R M A T I O N T o b e f i l l e d o u t b y A p p l i c a n t

Last

Firs t

Mi dd l e I ,1 ,1

R E S I D E N C E / A D D R E S S

C i t y / M un i c ipa l i t y

P rov ince r r T

TBarangay

~ ] [ ~ | l 1 T Tj i_

. _

i i T TJ L

House No. / S t ree t~1 1 1 T

I 1 II 1 I I J I L

C I T I Z E N S H I P j By b i r th Na tu ra l i z ed Re ac qu i r ed

If n a t u r a i i z e d / r e a c q u i r e d , s t a t e date of n a t u r a l i z a t i o n / r e a c q u i s i t i o n an d C e r t i f i c a t e Number of n a tu r a l i z a t i on o rde r of a p p r o v a l o f r e a c q u i s i t i o n )

Date of Natura l iza t ion/

Reacqu i s i t i o n

Month Day Year Cert i f ica te No. /Order of Approval

P E R I O D O F R E S I D E N C ENo. of Years

In the City / Mun [

No. of Monthsr ~ ~ iI in the Philippines

No. of Years

r l

P R O F E S S I O N / O C C U P A T I O N T I N r m -

. I P e r s o n w i t

I l l i t e r a t e | _ J Disability

Ass i s t ed by : .(Please All-up Assistor's Oath)

G E N D E Rj M a le J Fema le

H e igh t We igh t

D A T E O F B I R T H

r j . r"T"J J_ _ i i

Month Day

P L A C E O F B I R T H

Ci t y /M un

Pro v in ce

Year

C I V I L S T A T U S

S i ng l e ^ J w i d o w / e r

^ M a r r i e d ^ L e g a l l ySe pa ra t ed

Name of Spouse , i f marr ied

N ME O F F A T H E R

Last

First

M i d d l e

J I L

N ME O F M O T H E R

Last

First

" " T

i 1_I j 1 1 ]

1 I I fi. ~ l

M Mr M i d d l e i T I ~

PA R T 2 O A T H R O L L E D T H U M B P R I N T S / S P E C I M E N S I G N A T U R E S

I d o so l e m n ly swea r tha t t h e above s t a t em en t s r ega rd ing m y pe r so n a r et r u e and c o r r ec t ; t h a t I possess a l l the qu al i f ica t ions and non e of thedisqual i f ica t ions of a voter ; and t h a t I h ave no pend ing app l i c a t i on fo r r eg i s t r a t i onin an y c i t y /mun ic i p a l i t y.

| 1 fr I | ] r

I'l I I LMonth Da y Ye a r

Signature of ApplicantAbove Printed Name

EO / Adm inistering Officer(Signature above Printed Name)

L e f t h u m b

2 .

R i g h t h u m b

3 .

P A R T 3

M A p pro ve d

| D isap p roved

A C T I O N B Y T H E E L E C T I O N R E G I S T R A T I O N B O A R DDay

] T] Date

Wi t h p r e c in c t a s s i gn me n t No .

R e a s o n f o r d i s ap p r ov a l

M e m b e r(S ign a t u r e a b o v e P r i n t ed Name)

Chairman of the Board( S i g n a t u r e ab ove P r in t ed Name)

M e m b e r( S i g n a t u r e ab ov e P r i n t ed Nam e)

P A R T 4 V O T E R I D E N T I F I C A T I O N N U M B E R T o b e f i ll e d o u t b y E l e c t io n O f f i c e r )

C I T Y / M U N /

D I S T R I C T C O D E N A M E C O O E

P R E C I N C T N O . Y E A R

D AT E O F B I R T H



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Republic of the PhilippinesC O M M I S S I O N ON E L E C T I O N S

CEF-1D

A P P L I C AT I O N F O R C H A N G E / C O R R E C T I O N OF E N T R I E S /I N C L U S I O N O F R E C O R D I N T H E B O O K O F V O T E R S A N D

R E I N S TAT EM E N T O F N A M E I N T H E L I S T O F V O T E R S .

A P P L I C A T I O N F O R C H A N G E / C O R R E C T I O N OF E N T R I E S

hange of name by reason of marriageor by virtue of a court order

Correction of wrong or misspelledname in the list of voters

orrection of anyother entry

T H E E L E C TI O N R E G I S T R AT I O N B O A R D

City/Municipali ty ofProvince of

T h r o u g h : The Election Officer

Dear S i r /Madam:

I,First name/Middle name/Last name

a duly registered voter, do hereby reques t tha t my

, Fi l ipino, born onmonth/day/year

as recorded in the listinformation to be changed or corrected)

for Precinct No. _, wi th address at(Sitio, Barangay, Municipality)

be changed from to(Present

data) Ne w data)That sa id change/cor rec t ion is necessary an d va l id as e v idenced by the a t tached cer t i f ica t ion/order of

the court.

t _

uu.u.Ozou

L U

IHr_O_ -

Ou

(S ignature above Pr in ted Name)

SU BSCRIBED AND SWORN to before me on the above da te .

E O / C h a i r m a n of the Elec t ion Regis t ra t ion B oard(Signature above Pr in ted Name)

A P P L I C A T I O N F O R I N C L U S I O N OF R E C O R D S I N T H E B O O K OF V O T E R S / R E I N S T A T E M E N T

O F N A M E I N T H E L I S T OF V O T E R S

nclusion of VRR in the precinct book o f'voters

1 R " arReinstatement of registered voter whosename has been omitted in the list of voters




Dear S i r /Madam:

I ., Filipino, born onFirst name/Middle name/l a st name month/day/year

with address at ,a duly registered voter, do h e r eby r eques t t ha t my n a m e w h i c h has b e e n o m i t t e d in the list of v o t e r s / m yregistrat ion record which has not been inc luded in the precinct book of v o t e r s of Prec inc t no.be reinstated/included therein.

The said re ins ta tement of name/ inc lus ion of registrat ion record is n ece s s a r y and valid.

(S ignature above Pr in ted Name)SUBSCRIBED AND SWORN to before me on the abov e date.

EO/Chairman of the Election Registration BoardSignature above Printed Name)

Not i ce t o t he a p p l i c a n t : If your biometrics, i.e. p hotograph, signature and fingerprints had not been captured digitally, please accomplishth e form at the back.



4/6

A p p l i c a t i o n No. Precinct No.

Instructions : 1) Accomplish separately in three copies; 2) print legibly; 3) check the appropriate box.

PART 1

NAME

PERSONAL INFORMATION To be ill e out b y Applicant )

Lasti r r T I r r i r TI I

i l lj. i J t i i i i J . .i

First I

Middle i

i I i

T f 1

I l l

I I I

RESIDENCE/ADDRESS

City/ Municipality

House No. / Street

Province

Barangay

CITIZENSHIP y Birth ^Naturalized eacquired

( I f n a t u r a l i z e d / r e a c q u i r e d , s t a t e d a t e of n a t u r a l i z a t io n / r e a c q u l s l t i on a n d C e r t i fi c a t e N u m b e r of n a t u r a l i z a t io n / o r d e r of a p p r o v a l o f r e a c q u i s i t i o n )

Date o f Naturalization/ Month Day Year Certificate No./ Order o f ApprovalReacquisition j i j - j i - j j j i j

PERIOD OF RESIDENCENo. of Years

' ] iIn the City / Mun i i j

No. of Months No. of YearsIn the Philippines

PROFESSION/OCCUPATION TIN

Illiterate t ^ r ^ n t ^ V ^1 1 _ . J a _ . 0 ~ ,

Assisted by:.

Disabled/ ,

(Please fill-up Assistor' s Oath)

G E N D E R

_ Male J FemaleHeight Weight

D AT E OF B I R T H

Month Day

P L A C E OF B I R T H

City/ Mun

Province

Year

C I V I L S T AT U S^ Single | ]widow/ er

^ M a r r i e d LegallySeparated

Name of Spouse, if married

M AME OF FATHER' Last [ j | j i " NAME OF MOTHERLastFirst i

I I ...

r f-1 J --t V

Middle

First

Middle i

PA RT 2 OATH ROLLED THUMBP RINTS / SPECIM EN SIGNATURES

I do solemnly swear that the above statements regarding my person aretrue and correct; that I possess all the qualifi cations and none of thedisqualifications of a voter; that I have no pending appli cation for registrationin any city/ municipality; and that I am not registered in any precinct in thePhilippines.

DAI E

Month Day Year Signature of ApplicantAbove Printed Name

EO Administering Officer(Signature above Printed Name)

eft Thumb

2 .

Rght Thumb

3.

PART 3 AC TION BY THE ELECTI ON REGI STRATI ON BOARD

Approved

Disapproved DateI With precinct assignment No.

Reason f or disapproval

Member(Signature above Printed Name)

Chairman of the Board(Signature above Printed Name)


PART 4 V O T E R I D E N T I F I C AT I O N N U M B E R ( To b e ille out by E ect ion Off icer)C I T Y / M U N

D I S T R I C T C O D E

ACKNOWLEDGEMENT RECEIPT

Application for Registration

L a s t n H T T T T T TR r s t LZTIIITZD.1TZTIMiddle i . ]

I i

D AT E Of B I RT H

Application No.

This is to acknowledge receipt of your Application forregistration. You are not yet registered unless approved bythe Election Registration Board/ (ERB). You need not appearIn the ERB hearing unless required throil_h a written notice.

EO/ Interyiewer Signature Above Printed Nan-



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'\&\ Rep ubl ic of the Phi l ippin esC O M M I S S I O N O N E L E C TI O N S

CEF-1DA P P L I C A T I O N F O R C H A N G E / C O R R E C T I O N O F E N T R I E S /

I N C L U S I O N O F R E C O R D I N T H E B O O K O F V O T E R S A N DR E I N S T AT E M E N T O F N A M E I N T H E L I S T O F V O T E R S .

A P P L I C AT I O N F O R C H A N G E / C O R R E C T I O N O F E N T R I E S

T C h a n g e o f n a m e b y r e a s o n o f m a r r i a g e[ J o r by v i r tue o f a cour t o rde r




Dear Si r /Madam:

I

o r r e c t i o n o f w r o n g o r m i s s p e l l e dname in the l i s t o f vo te r s

o r rec t ion o f anyo the r en t ry

First name/Middle name/Last name

a duly registered voter, do hereby request that my

, Fil ipino, born onmonth/day/year

as recorded in the l ist(information t o be changed o r corrected)

for Precinct No. , with address at( S i t i o , B a r a n g a y, M u n i c i p a l i t y )

toe changed f rom(Present data) (New data)

That sa id change/correc t ion i s necessary and va l id as evidenced by the a t tached cer t i f ica t ion/order ofthe court .

(S ignature above Pr in ted Name)

SUBSCRIBED AND SWORN to be fo re me on t he above da t e .

EO/ Ch ai rm an of the Elec t ion Regis t ra t ion Boa rd(S igna tu re above P r in t ed Name)

A P P L I C AT I O N F O R I N C L U S I O N O F R E C O R D S I N T H E B O O K O F V O T E R S / R E I N S T AT E M E N TO F N A M E I N T H E L I S T O F V O T E R S

nc lus ion o f VRR in the p rec inc t b ook o fvo te r s I 1 e i n s t a t e m e n t o f r e g i s t e r e d v o t e r w h o s eame has been omi t t ed in the l i s t o f vo te r s

T H E E L E C T I O N R E G I S T R AT I O N B O A R DCity/Municipali ty ofProvince of

T hro ug h : The Election Officer

Dear Si r /Madam:

I, _, Fil ipino , born onFirst name/Middle name/Last name month/day/year

with add ress a t ,a du ly r eg i s t e r ed vo t e r, do he reby r eques t t ha t my name wh ich has been omi t t ed i n t he l i s t o f vo t e r s /myregis t ra t ion record which has not been inc luded in the prec inc t book of vote rs of Prec inc t no . ,be re ins ta ted/ inc luded there in .

The sa id re ins ta tement of name/ inc lus ion of regis t ra t ion record i s necessary and va l id .

(S igna tu re above P r in t ed Name)SUBSCRIBED AND SWORN to be fo re me on t he above da t e .

EO/Ch a i rman o f t he E l ec t ion Reg i s t r a ti on Boa rd(S igna tu re above P r in t ed Name)

N o t i c e t o t h e a p p l i c a n t : I f y o u r b i o m e t r i c s , i .e . p h o t o g r a p h , s i g n a t u r e a n d f i n g e r p r i n ts h a d n o t b e e n c a p t u r e d d i g it a l ly, p l e a s e a c c o m p l i s hth e form a t t he b ack .



6/6

A p p l i c a t i o n No.

c nP r e c i n c t No .

i ~ T T T Instructions : (1) Accomplish separately in three copies; (2) print legibly; (3) check th e appropriate box.

PA R T 1N A M ELast

P E R S O N A L I N F O R M AT I O N To be f i l l e d o u t b y A p p l i c a n t

First

Middle

R E S I D E N C E / A D D R E S S

Ci ty /Munic ipa l i ty

Province

.j .. . ; L

Barangay

I r

House No . / S t r ee t

ii

i j I l lC I T I Z E N S H I P By birth n Natura l i zed eacquired(i f naturalized/reacquired, state date of naturalization/reacquisib on a nd Certificate Numb er of naturalization/order of approval of reacquisition)

Date of Natural izat ion/

Reacquisi t ion

M o n t h D a y Ye a r Cert i f icate No./Order of Approval

i L_J I J i i._

P E R I O D O F R E S I D E N C EN o . of Ye a r s

in t he C i t y / M u n I | j

No . o f Months No . o f Yearsin th e Philippines j

P R O F E S S I O N / O C C U PAT I O N T I Nj j

[ | Illiter ate

Ass i s t ed by : .

Person with 'Disability

(P lease f i l l-up Ass l s to r s Oa th )

G E N D E R_ Male J Female

Height Weight

D AT E OF B I RT H

M o n t h Day

P L A C E OF B I RT H

Ci ty /Mun

Province

Ye a r

C I V I L S TAT U SSing le ^Jwidow/er

~J Mar r i ed [ Legal lySepara ted

N a m e of Spouse , if mar r i ed

N A M E O F FAT H E RLas t

I l l| I1 1

i. i

i

L 1First i

t . . . 1I i i. I

ji

1J L

N A M E OF MOTHERLast

M i d d l e

First

Middle

M i l 1 1 1_ 1 1 1 J .1.1. 1

1 i. L L

I j [ M i l j

P A R T 2 O AT H R O L L ED T H U M B P R I N T S / S P E C I M E N S I G N AT U R E S

I do solemn ly swear that the above s tate men ts regard ing my pe r son aret rue and correct ; that I possess all the qual i f icat ions and none of thedisqual if icat ions of a voter ; and that I have no pending applicat ion for regis trat ionin any ci ty/municipal i ty.

S i g n a t u r e of App l i can tA b o v e P r i n t e d N a m e

EO / A d m i n i s t e r i n g O f f i c er( S i g n a t u r e a b o v e P r i n te d N a m e )

Lef t Thumb

2.

Righ t Thumb

3 .

PA R T 3

Approved

Disapproved

A C T I O N BY THE E L E C T I O N R E G I S T R AT I O N B O A R DM o n t h D a y

i m iDate

Ye a rT 1

With p rec inc t a s s ignment No.

R e a s o n fo r d i sapprova l


C h a i r m a n of the Board(Signature above Printed Name)


P A R T 4 V O T E R I D E N T I F I C AT I O N N U M B E R To be f i l l e d o u t b y E l e c t i o n O f f i c e rcrry/MUN/

D I S T R I C T C O D E N A M E C O D E

P R E C I N C T N O . Y E A R

D AT E O F B I RT H


Documents

AnnexDApplicationforChange Correction of Entries Inclusion of Record in the Book of Voters and Reinstatement of Name in the List of Voter Update