Republic of the Philippines )

__________________ ) Ss

AFFIDAVIT TO SUPPLY NAME

I, ____________, of legal age, Filipino single, a resident of
____________________, Philippines, after having been duly sworn to in
accordance with law, hereby depose and say:

1. That I was born as a healthy baby girl on _________________ at

________________________ to spouses _____________________ and
_____________________ and the fact of my birth was duly registered before
the Office of the Civil Registrar of ______________;

2. That recently, I secured a copy of my Certificate of Live Birth

before the Philippine Statistics Authority (PSA for brevity) as the same was
one of the requirements in ____________________;

3. That as I examine the said Certificate of Live Birth issued by

the PSA, I was surprised to notice that there is no entry as to my first
name;

4. That by this affidavit, I hereby declare for all legal intents and
purposes that my first name is ________________ and that I have been using
said name since childhood. In fact, in all my official documents and school
records which require me to indicate my first name, I always indicate my
first name as _______________; and

5. That I am executing this Affidavit in order to attest to the

truthfulness of the foregoing statement, to support my application to
supply my first name in my Certificate of Live Birth and for whatever legal
purposes this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_____________ in __________________

________________________
Affiant

SUBSCRIBED AND SWORN to before me this ____________ in

___________________.

Doc. No.: ______;

Page No.: ______;
Book No.: ______;
Series of ____________.