Republic of the Philippines )SS

Quezon City )

AFFIDAVIT OF SUPPLEMENTAL REPORT

I, ROSIE RIMORIN, Filipino, of legal age, married to Valle, and a

resident of P1-141, Pulines, Baguio City, Benguet, Philippines, having been
duly sworn in accordance with law, hereby depose and state:

That I was born on November 8, 1980 at Caba, La Union to Delfin

Rimorin and Gertrudes De Guzman;

That since I was young, I have always been known and called as
simply “ROSIE RIMORIN” and that it is the same 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 La Union 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 oftheir 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)