REPUBLIC OF THE PHILIPPINES )

PROVINCE OF T A R L A C )S. S.
MUNICIPALITY OF CONCEPCION )

AFFIDAVIT OF SUPPLEMENTAL REPORT

I, ROCKY CONCEPCION LACSA, of legal age, single and a resident of 299

Rosal, San Francisco, Concepcion, Tarlac, after being duly sworn to in accordance
with law, do hereby depose and say:

1. That I was born on July 27, 1987 to Spouses Ricardo Lacsa and
Loreta Concepcion in Concepcion, Tarlac;

2. That when I secured a copy of my Certificate of Live Birth with Registry

No. 87-1744 at the National Statistics Office (NSO), it was shown that
the space provided for in SEX (Male or Female) was left blank;

3. That it is my desire to register before the Local Civil Registrar of

Concepcion, Tarlac and the National Statistics Office, my true and correct
gender;

4. That the failure to state the place of birth in my birth certificate was
purely due to the inadvertence of the person who registered my birth to
completely fill up the information needed on the birth certificate at the
time of registration;

5. That I am executing this affidavit to attest to the truthfulness and

veracity of the foregoing statements to process the registration of my
gender (SEX) in the Local Civil Registrar and the NSO and for whatever
legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 22nd day of

August, 2014, in the Municipality of Concepcion, Province of Tarlac, Philippines.

ROCKY C. LACSA
AFFIANT

SUBSCRIBED AND SWORN TO BEFORE ME, on the date and place first
above written, affiant exhibiting to me his Voter’s ID No. 6916-0389A-
G2787RCL10000 issued by COMELEC Concepcion, Tarlac.

ATTY. JOSELITO C. CASTRO

NOTARY PUBLIC
Doc No. _____ Until December 31, 2015
Page No. ____ Rollo No. 49046
Book No. XII IBP No. 07355/1-07-08
Series of 2014 PTR No. 8794433/1-06-14
At Concepcion, Tarlac