REPUBLIC OF THE PHILIPPINES )

Done: ______________________________) S.S.

AFFIDAVIT OF INCLUSION OF MIDDLE NAME

I, _____________________, of legal age, married, American citizen

and a resident of _____________________, Philippines, after having
been duly sworn to in accordance with law, hereby depose and
state, to wit that:

1. I am an American Citizen with PASSPORT NO.

_________________ with expiry date on May 07, 2017 issued
by the government of the United States of America and my
complete name is _______________________;

2. I’am now a permanent resident of the Philippines and I was

issued an IMMIGRANT CERTIFICATE OF RESIDENCE NO.
_____________________ and ALIEN CERTIFICATE OF
REGISTRATION IDENTIFICATION CARD SERIAL NO.
_____________________ both issued by Bureau of Immigration;

3. Perusal of the aforesaid Alien Certificate of Registration

Identification and Immigrant Certificate of Residence does
not contain my middle Name: _______________;

4. It is my request that the new Alien Certificate of

Registration Identification and Immigrant Certificate of
Residence which will be issued would include/contain my
middle Name: ___________________;

5. I am executing this affidavit to attest to the truth of my

foregoing statements and to support my request that my
MIDDLE NAME be included in my IMMIGRANT
CERTIFICATE OF RESIDENCE NO. __________________ and
ALIEN CERTIFICATE OF REGISTRATION
IDENTIFICATION CARD SERIAL NO.__________________
and for all other legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

th
22 day of June, 2016 at ________________, Philippines.

___________________
Affiant
PASSPORT NO.: ________________
Issued On: ___________________
 SUBSCRIBED AND SWORN TO before me this 22th day of
June, 2016 at ____________________, Philippines. Affiants personally
appeared before me and hereby certify that she is the same person
who executed this instrument freely and willingly.

Doc. No. _________;

Page No. _________;
Book No. ________;
Series of 2016.