REPUBLIC OF THE PHILIPPINES)

CITY OF TARLAC ) S.S.

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

AFFIDAVIT OF DISCREPANCY

I, SAM L. MILBY, of legal age, Filipino, (single/married/widow) and a resident of

_______________________________, after having been duly sworn to in accordance
with law, depose and state THAT:

1. I was born on 15th day of the October 1960 to spouses Anna Lerma and John Milby;

2. I have been using the name SAM L. MILBY in all my documents and transactions;

3. However, when I obtained a copy of my birth certificate, I discovered that my surname

appearing thereon was erroneously written as "MELBY";

4. The names “SAM L. MILBY” and “SAM L. MELBY” refers to one and the same person;

5. I execute this Affidavit of Discrepancy of Surname to attest to the truth of the foregoing
facts and to explain the discrepancy in my birth certificate with regards my surname.

IN WITNESS WHEREOF, I have hereunto set my hand

this ___________________ in Makati City, Metro Manila, Philippines.

____________________
Affiant
SSS ID No. _____________

SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant exhibiting to me his/her competent evidence
of identity by way of __________________ issued at ______________
on __________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2013.