SOCIALIST REPUBLIC OF VIETNAM
Independence – Freedom – Happiness
STATEMENT OF BIRTH RE-REGISTRATION
To: ………………………………………………………………………………………….
Full name of informant: …………………………………………………………………………………………………..
Permanent/temporary residence: …………………………………………………………………………………………
ID card/Passport No.:…………………………………………………………………………………………………………..
Relation with birth re-registered person:…………………………………………………………………………….
Propose to re-register birth for the following person:
Full name: …………………………………………………………………………….Sex:……………………………………..
Date of birth:……………………………………………………………………………………………………………………….
Place of birth:………………………………………………………………………………………………………………………
Ethnic group:………………………………………………..Nationality:…………………………………………
Native country (1):………………………………………………………………………………………………………………
Permanent/temporary residence: …………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………..
Full name of father:…………………………………………………………………………………………………………
Ethnic group:………………………………………………Nationality:………………………………………………………
Full name of mother:……………………………………………………………………………………………………….
Ethnic group:……………………………………………….Nationality:…………………………………………………….
Re-registered birth at: ………………………………………………………………………………………………………….
…………………………………………………………………………day………..month………..year……………
We assure that above statements are true and bear responsibility before the law on our assurance.
Propose………………………………………………………………….. to register.
Done at:…………………………………………
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Day …………month…………year…………
Informant