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REPUBLIC OF THE PHILIPPINES)

City of Cebu) S.S.


x--------------------------x
AFFIDAVIT OF SUPPLEMENTAL REPORT
I, _____________________, Filipino, of legal age, married and a resident of
___________________________________, Philippines having been duly sworn in
accordance with law, hereby depose and state:
1. That I was born on ____________________, at Cebu Maternity House,
Cebu City, Philippines to the spouses _____________________ and
_______________________;
2. That since birth until present, I have been using the name
___________________ as evidenced in my baptismal certificate,
school records and representation in the community;
3. That when I secured a copy of my Certificate of Live Birth with the
National Statistics Office under Registry Number _________________,
it was shown that I was registered therein with a first name
BABY;
4.

That it is my desire to register in the said Office of the Civil


Registrar and National Statistics Office (NSO) with a first name
_________________;

5. That the failure to state my true and correct name was purely due to
the inadvertence of my parents who failed to do so because of their
uncertainty in deciding as to what name would be given to me at
the time of the registration of the facts of my birth with the said
office;
6. As such, I execute this Affidavit to certify or attest to the truth of
the foregoing facts and to process the registration of the above
mentioned name with the Office of the Cebu City Civil Registrar and
National Statistics Office and for whatever legal purpose that this
Affidavit may serve.
IN WITNESS WHEREOF, I have set my hand this 1 st day of March,
2012, in Cebu City, Philippines.
____________________________
AFFIANT
SSS I.D. No. ______________________
Issued at Cebu City
SUBSCRIBED AND SWORN to before me, this 1st day of March, 2012
by the Affiant whom I have identified through competent evidence of identity
and who exhibited her Government Issued Identification Number as per
description appearing below her name.
Doc No.: _____;
Page No.: _____;
Book No.: _____;

Series of: 2012.