Republic of the Philippines )

Province of Bohol ) S.S.

City of Tagbilaran )

AFFIDAVIT FOR SUPPLEMENTAL REPORT

(FOR THE CORRECTION OF ENTRIES IN THE CERTIFICATE OF LIVE BIRTH OF DAUGHTER)

I, ___________________, Filipino, of legal age, married, and with postal address at

__________________l, Philippines, after being duly sworn in accordance with law, do hereby
depose and say that:

1. That I am the applicant for the processing of the Supplemental Report of:

X of the Certificate of Live Birth of ________________ registered in the Local Civil

Registry Office (LCR) of Dauis, Bohol on _________________;

2. The original copy of her Certificate of Live Birth was forwarded to the Philippine
Statistics Authority (PSA);

3. When a copy of her Certificate of Live Birth was secured from the Local Civil Registry
Office of Dauis, Bohol, it was discovered that the entries were written under the
following items:

MIDDLE NAME OF CHILD: FROM “D.” TO DELA CRUZ;

MOTHER’S MIDDLE NAME: FROM NO MIDDLE NAME TO ORACION;
FATHER’S MIDDLE NAME: FROM MIDDLE INITIAL “O.” TO ORACION;

4. Subsequently, when a copy of her Certificate of Live Birth was secured from the
Philippine Statistics Authority (PSA), it was also discovered that the entries were written
under the following items:

MOTHER’S MIDDLE NAME: FROM MIDDLE INITIAL “M.” TO MICULOB;

FATHER’S MIDDLE NAME: FROM MIDDLE INITIAL “O.” TO ORACION;
MOTHER’S RELIGION: FROM “R. CATHOLIC” TO ROMAN CATHOLIC;
FATHER’S RELIGION: FROM “R. CATHOLIC” TO ROMAN CATHOLIC:

5. There was a failure to supply the said items due to simple mistake or negligence on the
part of the person causing the registration of my daughter’s birth;

6. The entries to be indicated therein should be the following:

For her Certificate of Live Birth issued by the Local Civil Registry Office of Dauis, Bohol:

MIDDLE NAME OF CHILD: FROM “D.” TO DELA CRUZ;

MOTHER’S MIDDLE NAME: FROM NO MIDDLE NAME TO MICULOB;
FATHER’S MIDDLE NAME: FROM MIDDLE INITIAL “O.” TO ORACION;

For her Certificate of Live Birth issued by the Philippine Statistics Authority:

MOTHER’S MIDDLE NAME: FROM MIDDLE INITIAL “M.” TO MICULOB;

FATHER’S MIDDLE NAME: FROM MIDDLE INITIAL “O.” TO ORACION;
MOTHER’S RELIGION: FROM “R. CATHOLIC” TO ROMAN CATHOLIC;
FATHER’S RELIGION: FROM “R. CATHOLIC” TO ROMAN CATHOLIC:
 7. I am requesting the concerned authorities to supply the omitted pieces of information in
my daughter’s Certificate of Live Birth; and

8. This Affidavit for Supplemental Report is voluntarily executed in order to attest to the
truthfulness of the foregoing statements for all legal intents and purposes.

IN WITNESS WHEREOF, I am affixing my signature this 10 th day of August, 2023 in the

City of Tagbilaran, Bohol, Philippines.

_______________
Affiant
National ID No._____________
Issued by:_________________

SUBSCRIBED AND SWORN to before me this 10th day of August, 2023 in the City of
Tagbilaran, Bohol, Philippines.

Doc. No. 313;

Page No. 64;
Book No. 21;
Series of 2023.