REPUBLIC OF THE PHILIPPINES)

PROVINCE OF KALINGA)
TABUK CITY) S.S. 

AFFIDAVIT OF SUPPLEMENTAL REPORT

I, JHENNY ADAY YAG-AO, Filipino citizen, of legal age, single, and

currently residing at Liwan West, Rizal, Kalinga, after having been sworn to
in accordance with law, hereby depose and state , the following, to wit:

1. That the facts and other circumstances of my birth were duly

registered with the Office of the Local Civil Registar of Liwan West, Kalinga;

2. That when I secured a copy of my Certificate of Live Birth from the

Philippine Statistics Authority (PSA), I discovered that the middle names of
my father and mother were inadvertently not indicated therein, a copy of
which is hereto attached as Annex “A” of this affidavit;

3.That the true and correct middle names of my father and mother are
Busaiya and Buyao respectively as evidenced by their Marriage Contract
which is hereto attached as Annex “B” hereof;

4. That I am executing this affidavit in good faith to attest to the truth

of the foregoing averments to the best of my personal knowledge and belief
in order to request the Local Civil Registar of Liwan West, Rizal, Kalinga to
supply the middle names of my father and mother as BUSAIYA and BUYAO
respectively in my Certificate of Live Birth in order to complete the lacking
entry thereon, and for whatever legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 8th day of

July at Tabuk, City, Kalinga.

JHENNY ADAY YAG-AO

Affiant

SUBSCRIBED AND SWORN to before me this 8th day of July at Tabuk

City, Kalinga Province, the affiant exhibiting to me her National Bureau of
Investigation (NBI) document No. 21884024.

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