Affidavit of Discrepancy

I, _____________________, of legal age, married, and with address at

______________________________________________________, under oath, state:

1. THAT my name is ____________________ as stated and registered in my birth certificate

issued by office of the Civil Registry of ______________________. A copy of my birth certificate
is hereto attached as ANNEX “A”;

2. THAT the name ___________________also appears in my passport which was issued based
on the data appearing in my birth certificate. A copy of the page of my passport where my name
and picture appears is hereto attached as ANNEX “B”;

3. THAT since childhood, my friends and acquaintances call me ________and thus since then I
have been accustomed to using the name ____________________in my personal records,
transactions and communications;

4. THAT the name ____________________ and _____________________ refer to one and the
same person, the herein Affiant;

5. THAT I am executing this Affidavit to attest to the truth of the foregoing facts and to use the
same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this _________________ at _____________.

________________________
Affiant

SUBSCRIBED AND SWORN to before me this _______________ at ___________, Affiant exhibiting to

me his _____________ bearing No. ______________________________ issued at ______________ on
_________________.

Doc No. ________;

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