Republic of the Philippines )

) S.S.
Done in the City of Baguio )

AFFIDAVIT OF SUPPLEMENTAL REPORT

I, CARMENCITA FIAL CHAVEZ, of legal age, Filipino Citizen, widow, with

residence and postal address at No. 7, Alfonso Tabora, Baguio City, Philippines, after having
been sworn to in accordance with law, hereby depose and state:

1. That I was born on November 2, 1956 at the 607 Gastambide St., Sampaloc,
Manila, Philippines by the spouses Teofilo P. Fial and Emilia C. Fial as appearing in my
Certificate of Live Birth hereto attached as Annex “A” and made an integral part of this
affidavit;

2. That when I acquired a copy of my Certificate of Live Birth from the Philippine
Statistics Authority (PSA), I discovered that my Place of Birth which should be “MANILA”
was not indicated;

3. That the non-indication of my place of birth in my certificate of live birth might be

due to oversight and/or honest mistake committed by the person/clerk who entered the facts of
my birth or by my parents when they filled the facts of my birth and not done for any illegal
motive or purposes whatsoever;

4. That I am executing this affidavit to attest to the truth and veracity of its contents
and for the purpose of requesting the Local Civil Registry of Baguio City to supplement my
place of birth to MANILA and to endorse the same with the Philippine Statistics Authority
(PSA) and for all legal intents and purposes it may properly serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 16 th day of November

2017 in the City of Baguio, Philippines.

CARMENCITA FIAL CHAVEZ

Affiant

SUBSCRIBED AND SWORN to before me this 16th day of November 2017 in the
City of Baguio, Philippines. Affiant exhibited to me her Senior Citizen ID bearing No. 37300
issued on November 14, 2017 at Baguio City.

Doc. No. 15; ROMEO F. BUSLAYAN, JR.

Page No. 3; Notary Public
Book No. XLI; Until December 31, 2017
Series of 2017. PTR No. 2438760-Jan. 4, 2016
IBP No. 1003684-Jan. 4, 2016-Baguio-Benguet
N.A. No. 32-NC-16-R