REPUBLIC OF THE PHILIPPINES)

CITY OF TACLOBAN ) S.S.

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

AFFIDAVIT OF SUPPLEMENTAL REPORT

I, _______________________ of legal age, Filipino, married, and a resident of

__________________________________________, after having been duly sworn to in
accordance with law, depose and state THAT:

That I was born on November 1, 1000 at ____________, Leyte to the Spouses

________________________________:

That since birth until present, I have and have been using a Middle Name “XXXX” and
that it is the same Middle Name that I have been using in all my documents and
identification papers;

That when I secured a copy of my Certificate of Live Birth with the National Statistics
Office under Registry No. VVVV, it appears that I do not have Middle Name indicated
therein;

That it is my desire to register in the said Office of the Civil Registrar and the National
Statistics Office with a middle name “XXX”;

That the failure to state my complete and correct name is due to negligence in the
recording and review in the registration of my live birth;

I am executing this Affidavit to attest to the truth of the foregoing and to process the
registration of the abovementioned name with the Office of the Civil Registrar of
_____________________ Leyte and National Statistics Office and for whatever legal
purpose that this Affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 16th day of January 2018 in
Tacloban City, Philippines.

Affiant

SUBCRIBED AND SWORN TO before me this 16th day of January 2018 in Tacloban
City, Philippines, affiant exhibiting to me her competent evidence of identity as indicated
below her name.