Republic of the Philippines )

City of Manila ) S.S.

x--------------------------x

AFFIDAVIT OF SUPPLEMENTAL REPORT

I, , Filipino, of legal age, married and a resident of No. 60 Mangyan

Street, La Vista, Quezon City, Philippines, having been duly sworn in
accordance with law, hereby depose and state that:

1. I was born on May 1, 1963 at Our Lady of Lourdes Hospital,

Manila to the Spouses;

2. Since I was young, I have always been known and called by the
first name "" and that it is the same first name that I have been
using in all my documents and identification papers1;

3. However, it appears from the Certificate of Live Birth2 registered

at the Office of the Local Civil Registrar of Manila under Registry
No. 563 (263) that I was registered therein without a given first
name;

4. On April 6, 2018, I authorized to secure a copy of my Certificate

of Live Birth from the Philippine Statistics Office in Manila.

5. However, the said office issued a Certification of Negative Intact3

stating that there appears to be no record of birth under the name

6. Thus, it is my desire to be registered with the said Office of the

Civil Registrar of Manila and Philippine Statistics Office with the
name "";

7. The failure to state my first name was purely the

inadvertence of my parents who failed to do so because of their
uncertainty at first as to what name would be given me at the
time of the registration of the facts of my birth with the
said office;

As such, I execute this Affidavit to attest to the truth of the

foregoing facts and to process the registration of the above-mentioned
1 Attached to form an integral part of this affidavit is copy of the said documents
marked as Annex “A” to “C”
2 Attached to form an integral part of this affidavit is copy of the Certificate of Live
Birth marked as Annex “D”
3 Attached to form an integral part of this affidavit is copy of the Certificate of
Negative Intact marked as Annex “E”
name with the Office of Civil Registrar of Manila and Philippine
Statistics Office and for whatever legal purpose that this Affidavit may
serve.

IN WITNESS WHEREOF, I have set our hands this

_____________, in the _____________, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me, this _____________,

by _____________ who exhibited to me (his/her) Community Tax
Certificate No. _____________ issued at _____________, Philippines on
_____________.

Notary Public

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of ______;