REPUBLIC OF THE PHILIPPINES )

CITY OF BACOLOD ) S.S.

x---------------------------------------------x

AFFIDAVIT OF SUPPLEMENTAL REPORT

I, RONILO S. RUIZ, Filipino, of legal age, married, and a resident of

Prk. Pag-isa, Brgy. Bata, Bacolod City, having duly sworn to in accordance
with law, hereby depose and state that:

1. I was born on September 14, 1984 at Corazon Locsin Montelibano

Memorial Hospital, Bacolod City to spouses Emma S. Ruiz and Braulio
B. Ruiz;

2. Since I was a child, I have always been known and called by the first
name “RONILO” and that is the first name that I have been using in all
my documents and identification papers;

3. When I secured a copy of my Certificate of Live Birth with the National

Statistics Office of Bacolod City, it appears from their records that I was
registered therein without a given first name;

4. The first name “RONILO” was supplied on ______________________

with the Office of the Civil Registrar of Bacolod City;

5. It is my desire to register with the Office of the Civil Registrar and

National Statistics Office with a first name “RONILO”;

6. 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 at the time of the registration of the facts of
my birth with the said office;

7. As such, I am executing this Affidavit to certify or attest to the truth of

the foregoing facts and for whatever legal purposes it may serve

IN WITNESS WHEREOF, I have hereunto set my hand this

_________________, in Bacolod City, Philippines.

RONILO S. RUIZ
Affiant

SUBSCRIBED AND SWORN to before me this ________________ at

Bacolod City, Philippines. Affiant exhibiting to me his Voter’s Identification No.
_________________________.

Doc. No. ________;

Page No. ________;
Book No. ________;
Series of 2016.