REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF FOREIGN AFFAIRS Date:

THIS FORM IS NOT FOR SALE. DO NOT LEAVE ANY SPACES BLANK, INDICATE N/A IF NOT APPLICABLE.
PROVIDING FALSE STATEMENT IS PUNISHABLE BY LAW (R.A. 8239)

Foreign Service Post: BERNE GENEVA

AFFIDAVIT OF DISCREPANCY
(ONE AND THE SAME PERSON)

I, _________________________, Filipino, single/married to __________________,

of legal age, with address at _________________________________________________
after having been duly sworn to in accordance with law hereby depose and say:

1) The ________________ issued on ________________ at _________________

indicates the name/birthday/place of birth of my __________________________
as _________________________.

2) On the other hand, in the ________________ issued on ___________________

at ____________________ the name/birthday/place of birth of my ___________
is indicated as __________________________.

3) Both names/documents pertain to one and the same person.

4) I am executing this affidavit to attest to the truth and for whatever legal purposes
it may serve.

IN WITNESS WHEREOF, I hereby affix my signature this ___________________

___________at the _________________________.

___________________________________________
Signature of Affiant over Printed Name

___________________ )
___________________ ) S.S.
___________________ )

SUBSCRIBED AND SWORN to before me this ________________________ at the _____________________

affiant having exhibited to me his/ her _______________passport no. ___________________ issued in
__________________on __________________ and valid until ___________________________.

Date: _______________
Service No.: _________
O.R. No.: ___________ (seal) __________________________________
Fee Paid: ___________ Consul of the Republic of the Philippines