Republic of the Philippines )

) SS

AFFIDAVIT OF SUPPLEMENTAL REPORT

I, ______________________________., married, of legal age, Filipino Citizen

and presently residing at ____________________, Philippines after having been
duly sworn to in accordance with law do hereby depose and say that:

1. I was born on _______________ at Baguio City;

2. In my Certificate of Live Birth which was secured from the Philippines
Statistics Authority, my FIRST NAME was incorrectly registered as BABY
BOY;
3. My true and correct FIRST NAME is ___________
4. The reason why my “FIRST NAME” was incorrectly registered as BABY
BOY in my Certificate of Live Birth was due to inadvertence, honest
mistake and was not made for any unlawful purpose;
5. I am executing this affidavit to attest to the truth of the foregoing in
supplying my first name _____________. in my Certificate of Live Birth
with the PSA-OCRG Copy and for all legal intents and purposes this may
well serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

January 5, 2021 at Baguio City, Philippines.

_______________________
AFFIANT

SUBSCRIBED AND SWORN TO before me this January 5, 2021 at

Baguio City, Philippines. Affiant presented to me proper identification, the
specifics of which are indicated below the name.