Republic of the Philippines )

Province of _______ )
Municipality of _______ ) S.S.
x ------------------------------- x

AFFIDAVIT OF SUPPLEMENTAL REPORT

I, _________________, Filipino, of legal age, __________, and a

resident of ___________________________ Philippines, having been duly sworn in
accordance with law, hereby depose and state:

1. That I was born on _____________ at ___________________ to the Spouses

_______________ and ______________;

2. That my gender had always been male and such fact is evidenced in my
baptismal certificate, school records and representation in the community;

3. That when I secured a copy of my Certificate of Live Birth with the Philippine
Statistics Authority, it was shown that no entry was made for my gender;

4. That it is my desire to have this lapse corrected by registering the male gender
in the records of the Office of the Municipal Registrar and the Philippine
Statistics Authority;

5. That I execute this Affidavit to certify and attest to the truth of the foregoing
facts and to process the registration of the above mentioned gender with the
Office of the Municipal Civil Registrar and the Philippine Statistics Authority
and for whatever legal purpose that this Affidavit may serve.

IN WITNESS WHEREOF, I have set my hand this 14th day of February, 2020,
at ________, _________.

JUAN DELA CRUZ

Affiant
ID No. __________

SUBSCRIBED AND SWORN to before me this ___________________,

by __________ who exhibited to me his I.D No. __________ at _________,
________.

Doc. No. ________;

Page No. ________;
Book No. ________;
Series of 2020