REPUBLIC OF SOUTH SUDAN

CENTRAL EQUATORIA STATE

Civil Registry Office

Birth and Death Registration - Juba, South Sudan

Tel: +211 123 456 750 | Email: civilregistry@ces.gov.ss

BIRTH CERTIFICATE APPLICATION FORM

Form Reference Number: CES/BC/2026/2939

Date Issued: 11/01/2026

INSTRUCTIONS: Complete all sections legibly. Attach: Hospital birth notification or affidavit, copies of parents' National IDs or passports, and marriage certificate (if applicable).

SECTION A: CHILD'S INFORMATION

1. Full Name of Child: *

2. Sex: *

3. Date of Birth: *

4. Place of Birth (Hospital/Home/Other): *

SECTION B: FATHER'S INFORMATION

5. Father's Full Name: *

6. Nationality:

7. National ID/Passport No:

SECTION C: MOTHER'S INFORMATION

8. Mother's Full Name: *

9. Nationality:

10. National ID/Passport No:

SECTION D: APPLICANT INFORMATION

11. Applicant's Full Name: *

12. Relationship to Child: *

13. Phone Number: *

14. Address: *

DECLARATION

I hereby declare that the information provided in this application is true and correct to the best of my knowledge. I understand that providing false information is a criminal offense punishable under the laws of the Republic of South Sudan. I authorize the Civil Registry Office to verify the information provided.

Applicant Signature:

Date:

FOR OFFICIAL USE ONLY

Registrar:

Registration Date:

Certificate Number:

OFFICIAL STAMP

Processing Fee: 1,000 SSP | Processing Time: 3-5 Working Days

Civil Registry Office - Central Equatoria State Government

Every Child Has the Right to Be Registered at Birth