Republic of the Philippines ]

Province of Leyte ]Ss

City of Tacloban ] Registry 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 with
law, 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 JOHN
MICHAEL 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 came
to know that my Middle Name is without entry;

5. I have been known publicly as JOHN MICHAEL LACERNA GRANDE and my

baptismal record and other documents bear the same name;

6. I am executing this affidavit in support of my application to Supply the MIDDLE

NAME 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 11th day of
September 2017 at Tacloban City.

JOHN MICHAEL LACERNA GRANDE

Affiant
ID #: ___________

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

ATTY. ALJUN B. DIAZ

Notary Public
Notarial Commission No. 2017-07-79
Roll of Attorney No. 67381; May 24, 2017
PTR OR No. 7660711; July 18, 2017
IBP OR No. 005037; 05-19-17; Leyte Chapter
MCLE COMPLIANCE No. Exempt-New Passer
Door 2, Apdo Apartment, Marasbaras, Brgy. 81, Tacloban City
Doc. No. 92;
Page No. 20;
Book No. I
Series of 2017