Republic of the Philippines…}

CITY OF ……………..}SS.
x--------------------------------x

AFFIDAVIT OF SUPPLEMENTAL REPORT

I, _______________________________, of legal age, Filipino and a resident of

_______________________________________, after having been duly sworn to in
accordance with law do hereby depose and state that:

1. I am the same _________________________ who was born on _______________

at _______________________________________;

2. As shown in the copy of my Certificate of Live Birth bearing No.

____________________, my GENDER was OMITTED;

3. My GENDER is ______________ as evidenced by the Medical Certificate issued by

___________________________MD, a duly licensed physician who personally
examined me; And,

4. I am executing this affidavit to attest the veracity of the foregoing facts and for the
supplemental report of my birth certificate.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

________________ in ___________________.

________________________
Affiant

SUBSCRIBED AND SWORN to before me this __________________ in

___________________. Affiant appeared before me, exhibited to me his ______________ ID
No. ________________ issued by ____________________ with expiry date on
_________________ and is personally known to me.

NOTARY PUBLIC