REPUBLIC OF THE PHILIPPINES)

Province of Masbate )
City of Masbate )S.S.
x--------------------------x

AFFIDAVIT OF SUPPLEMENTAL REPORT

I, ______________________________, of legal age, married, and a resident of

_____________________________________________, after having been duly sworn to in
accordance with, hereby depose and state:

1. That I am the biological mother of ______________________________ who was

born on July 26, 1998 on _______________________________;

2. That however, when I secured a copy of her National Statistics Office

(NSO) certified Certificate of Live Birth, it appears that the place of birth
was insufficiently filled, with the entry for “Province” left blank;

4. That it is my desire to have this error be corrected and that the Place of
Birth be completely filled with all the necessary information, from
Masbate Colleges Hospital, Rosero St., Masbate to Masbate Colleges
Hospital, Rosero St., Masbate City, Masbate;

5. As such, I execute this Affidavit to certify or attest to the truth of the

foregoing facts and to process the correction of the above- mentioned
entry in the Certificate of Live Birth of my daughter with the Office of the
City Civil Registrar, Masbate City and the National Statistics Office and for
whatever legal purpose this affidavit may serve.

In witness whereof, I have set my hand this _____________________ in Masbate

City, Philippines.

________________________
Affiant

SUBSCRIBED AND SWORN to before me this ______________________ in Masbate

City, Philippines.

NOTARY PUBLIC

Doc No. ____;

Page No. ___;
Book No. ___;
Series of 2018.