REPUBLIC OF THE PHILIPPINES )

GUAGUA, PAMPANGA ) S.S.

AFFIDAVIT OF DISCREPANCY

I, _____________________________________, of legal age, Filipino Citizen, residing at

_________________________________________________, after having been duly sworn to in
accordance with law do hereby depose and state:

1.) That to the best of my knowledge, belief and information my

____________________________ is “____________________________________” and not “
_______________________________________” as shown in my Birth Certificate and in all my
government issued Identification documents;

2.) That when I got my Driver’s License Card issued by the Land Transportation
Office it glaringly appeared that given name is “____________________________________”
instead of “____________________________________________”, hence a discrepancy;

3.) That my true and correct name is “__________________________________”

and not “ _____________________________________”;

4.) That I affirmed that my true and correct name is “________________________”

and not “_______________________________________”;

5.) That I am executing this Affidavit to attest to the truth and veracity of the
foregoing facts and for informing the Land Transportation Office relative to the discrepancy of
my name which appeared at my Driver’s License and respectfully request for the rectification of
the same.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________ day of

___________________ at Guagua, Pampanga.

__________________________________
AFFIANT

Identification Document ___________________________________________________

SUBSCRIBED AND SWORN to before me on this ______ day of

_______________________ at Guagua, Pampanga. Affiant exhibited to me his Identification
Document stated below his name.

Doc No. ______

Page No. _____
Book No. _____
Series of 20__.