REPUBLIC OF THE PHILIPPINES)

Quezon City ) SS.

AFFIDAVIT OF DISCREPANCY IN NAME

I, ___________, of legal age, single, and with address at _____________, under oath, state that:

1. The birth certificate issued on ____________ by the Civil Registrar of ____________indicates

my name as __________. A copy of my birth certificate is hereto attached as ANNEX “A”;

2. On the other hand, in the passport issued to me on ___________ by the Department of Foreign
Affairs NCR, my name is indicated as ____________. A copy of the page of my passport where
my name and picture appears is hereto attached as ANNEX “B”;

3. The names _________ and __________ refer to one and the same person, the herein Affiant;

4. 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 ____day of September 2018 at

Quezon City.

_____________________________
Affiant

SUBSCRIBED AND SWORN to before me this _______________ at Quezon City, Affiant

exhibiting to me his ________ bearing No. ______________________________ issued at
______________ on _________________.

Doc No. ________;

Page No. _______ ;

Book No. _______;

Series of ________.