REPUBLIC OF THE PHILIPPINES )

Province of ____________________ ) S.S.

City of ________________________ )

AFFIDAVIT

I, ____________________, of legal age, Filipino, single/married and a

resident of _________________________________, after having been duly
sworn to in accordance with law, hereby depose and say that:

1. I was born on ________________ at ________________ to Spouses

___________ and ______________, machine copy of my Certificate
of Live Birth issued by the National Statistics Office (NSO) is
hereto attached as Annex “A” and made an integral part hereof;

2. In my school records at the ________________________, my name

was erroneously recorded as “___________________”, instead of
my true and correct name which is
“__________________________”;

3. The names “________________” and “________________” refer to

one and the same person;

4. I am executing this Affidavit to attest to the truth of the

foregoing facts and to request the _________ school______
registrar to effect the necessary correction in my school records.

IN WITNESS WHEREOF, I have hereunto set my hand this ____

day of _________, 2015 in Quezon City, Philippines.

___________________
Affiant

SUBSCRIBED and SWORN to before me, this ____ day of

_________, 2015, affiant exhibiting to me his ID with number ________
which is valid until _______________.

NOTARY PUBLIC

Doc No. ____

Page No. ____
Book No.____