SUPPLEMENTAL REPORT

CITY OF MANILA

Name of Child: _________________________________________ Registry No: ________________

Date of Birth: ________________

Information item omitted: ____________________________________ _

_____________________________________

Name of informant: ___________________________________________

Relationship to the child: ______________________________________

Received by OCR: _____________________________________________

AFFIDAVIT

REPUBLIC OF THE PHILIPPINES }

CITY OF MANILA } S.S.

I, _____________________________ of legal age, ____________, ________________, presently residing

(name) (status) (nationality)
at ___________________________________________________, after having been sworn to in accordance with
(address)
the law hereby depose and state;

That the child named ____________________________________, w ho was born on

(name)
___________________________ at ______________________________________, MANILA. That the Certificate
(date of birth) (place of birth)

of Live Birth was registered at the City Civil Registry Office of Manila under Registry No. _________________.

That based on the said certificate, the parents of the above named child are
______________________________________ and _____________________________________________.
(father) (mother)

That the information _______________________________ under item no ______________ ____

(item omitted) (item no)
_______________________ was omitted because ______________________________________ _____.
(reason)

That I am executing this affidavit to attest the truth and veracity of the foregoing statements for legal intents
and purposes.

FURTHER AFFIANT SAYETH NAUGHT

IN WITNESS WHEREOF, I hereby affixed my signature this ________ of__________________at Manila,

Philippines.

________________________________
Affiant

SUBSCRIBED AND SWORN to before me this ________ of____________________________at Manila,

affiant exhibiting to me his/her CTC No. ____________________ issued on ________________________________
in _______________________.

NOTARY PUBLIC