REPUBLIC OF THE PHILIPPINES )

Province of Isabela
) S.S.
Municipality of Angadanan
)
x-----------------------x
AFFIDAVIT OF SUPPLEMENTAL REPORT
I, _____________________, Filipino, of legal age, and a resident of
___________________ having been duly sworn in accordance with law, hereby depose and
state:
That I was born on _____________ at _______________ to parents _____________;
That the facts surrounding my birth were registered at the Office of the Local Civil
Registrar at _______________;
That in my authenticated Certificate of Live Birth issued by the PSA, specifically in the
information for the Childs Place of Birth, the space for the entry Province was left
blank;
That in order to reflect my true place of birth, it is my desire that the entry _________
be placed in the space for Province under the information for Place of Birth;
As such, I execute this Affidavit to certify or attest to the truth of the foregoing facts and
for whatever legal purpose that this Affidavit may serve.
IN WITNESS WHEREOF, I have set my hand this _________________, at
____________________.

_________________________
Affiant
Drivers Lic. No. ______________
Valid until ____________
SUBSCRIBED
______________.

AND

SWORN

WITNESS my hand and seal.

to

before

me,

this

_________________

at