Republic of the Philippines)

Province of __________________)S.S.
City/Municipality of ___________)x - - - - -
AFFIDAVIT OF SUPPLEMENTAL REPORT
I, _____________, Filipino, of legal age, (single / married / widow), and
resident of _____________, Philippines, having been duly sworn in
accordance with law, hereby depose and state:
That I was born on _____________ at _____________ to the Spouses
_____________ and _____________;
That since I was young, I have always been known and called by the first
name "PEDRO" and that it is the same first name that I have been using in
all my documents and identification papers;
However, it appears from the records of the Office of the Civil
Registrar of _____________ City that I was registered therein without a given
first name;
That it is my desire to be registered with the said Office of the Civil
Registrar of _____________ City with the first name "PEDRO";
That the failure to state my first name was purely the inadvertence of my
parents who failed to do so because of their uncertainty at first as to what
name would be given me at the time of the registration of the facts of my
birth with the said office;
As such, I execute this Affidavit to certify or attest to the truth of the
foregoing facts and for whatever legal purpose that this Affidavit may serve.
IN WITNESS WHEREOF, I have set our hands this _____________, in the
_____________, Philippines.
Affiant
(JURAT)
Republic of the Philippines ]Province of Leyte ]SsCity of Tacloban ] Registr
y No.
____
AFFIDAVIT TO SUPPLY MIDDLE NAME
I, JOHN MICHAEL LACERNA GRANDE, of legal age, Filipino, single, a resident
of ________________, Philippines, after having been duly sworn to in accordance
withlaw, hereby depose and say: That---
1. I was born on __________ at __________________ City;
2. The birth certificate was registered in the Office of the Local City Civil
Registrar,Tacloban City, but without the MIDDLE NAME thus registration was
only as JOHNMICHAEL GRANDE only my First Name and Last Name are
supplied therein respectively;
3. That the registration without the entry was due to simple negligence;
4. Just recently, when I secured the copy of my birth certificate at the PSA, I
cameto know that my Middle Name is without entry;
5. I have been known publicly as JOHN MICHAEL LACERNA GRANDE and
mybaptismal record and other documents bear the same name;
6. I am executing this affidavit in support of my application to Supply the
MIDDLENAME of “LACERNA” in my Record of Birth;7. I attest to the truth
of the foregoing statement.
IN TRUTH WHEREOF, I have set and affix my signature this 11 th day of
September 2017 at Tacloban City.

JOHN MICHAEL LACERNA GRANDE

AffiantID #: ___________
SUBSCRIBED AND SWORN TO BEFORE ME, this 11 th day of September
2017in the City of Tacloban, Philippines, Affiant known to me and to me known to be
the sameperson who executed the foregoing instrument and acknowledged
to me that the same ishis free and voluntary act and deed.