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Republic of the Philippines)

Province of Tarlac )S.S.

City of Tarlac )


I, BENJIE POLIDO BAÑEZ, of legal age, Filipino, single, a resident of

Barangay Sta. Lucia, Victoria, Tarlac, after having been duly sworn to in accordance
with law, hereby depose and say: That---

1. I was born on September 18, 1990 at Tarlac City;

2. The birth certificate was registered in the Office of the Local City Civil
Registrar, but without the MIDDLE NAME thus registration was only as
BENJIE BAÑEZ only my First Name and Last Name are supplied therein

3. That the registration without the entry was due to simple negligence;

4. Just recently, when I secured the copy of my birth certificate at the PSA, I came
to know that my Middle Name is without entry;

5. I have been known publicly as BENJIE POLIDO BAÑEZ and my baptismal

record and other documents bear the same name;

6. I am executing this affidavit in support of my application to Supply the MIDDLE

NAME of “POLIDO” in my Record of Birth;

7. I attest to the truth of the foregoing statement.

IN WITNESS WHEREOF, I have set and affix my signature this ______ day
of ________________ at Tarlac City.



SUBSCRIBED AND SWORN TO BEFORE ME, this _________ day of

______________ in the City of Tarlac, Philippines, Affiant known to me and to me
known to be the same person who executed the foregoing instrument and
acknowledged to me that the same is his free and voluntary act and deed.

Doc. No. ______;

Page No. _______;
Book No. _______;
Series of 2018.