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REPUBLIC OF THE PHILIPPINES)

SANTIAGO CITY) S.S.


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AFFIDAVIT OF DISCREPANCY IN NAME

I, ARNEL JOSE y RAMOS, of legal age married, and with address at


Patanad,San Isidro, Isabela, after having been duly sworn to in accordance with
law do hereby deposes and states:

1. THAT I am married to JOANAMARIE RAMOS y ZAMORA since 2006;

2. THAT during the period of our marital union, we begot two children
and our eldest daughter named KIMBERLY HEART Z. JOSE[1] was
born on February 18, 2007;

3. THAT the name “KIMBERLY HEART Z. JOSE” and “KIMBERLY Z.


JOSE” refer to one and the same person;

4. THAT our daughter “KIMBERLY HEART Z. JOSE” was accidentally


bitten by a street cat owned by unknown person;

5. THAT our daughter “KIMBERLY HEART Z. JOSE” was given a


medical attention at IPIL ECHAGUE DISTRICT HOSPITAL and the
financial expenses we incurred will be reimbursed from RSPI;

6. THAT I am executing this Affidavit to attest to the truth of the


foregoing facts and to use the same for reimbursement of medical
expenses to be given by RSPI in our favor and for whatever legal
purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this 1st day of


June 2018 at Santiago City.

ARNEL JOSE y RAMOS


Affiant
Driver’s License No. B06-96-015841

SUBSCRIBED AND SWORN, to before me this 1st day of May, 2018 at


Santiago City, together with their identifying evidence required by these rules,
who signed the said instrument in my presence. I further certify that I have
personally examined the affiant and I am convinced that the same is heis own
free and voluntarily act and deed.
Doc. No. _____
Page No. _____
Book No. ____
Series of 2018

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Annex “A”