(baby's name), (gender) Yes.

(Mother's name) and (Father's name) are biological.

Mother's Name Date of Birth Nationality Current Residence Tel: Father's Name Date of Birth Nationality Current Residence Tel: Date of Birth: Date of Birth

Place of birth: The birth was delivered by (midwife's name) in rural areas of provinces, counties (cities), but she was not born in the hospital because of her relationship with the baby.

The state of the baby at birth is 1, good 2, fair 3 and poor.

If the above situation is not true, I am willing to bear legal responsibility.

Mother's signature: ID number: date: father's signature: ID number: date: (or guardian's signature: date:)

Reference signature: date:

Prove the relationship between the witness and the baby