(Affidavit of Discrepancy - Middle Name)

REPUBLIC OF THE PHILIPPINES)

Province of ____________________) S.S.

City/Municipality of _____________)

x-----------------------x

AFFIDAVIT OF DISCREPANCY

I, _____________, of legal age, Filipino, (single / married / widow), and a resident of

_____________, Philippines, having been duly sworn in accordance with law, hereby depose and state:

1. That in my Certificate of Live Birth as recorded in the Office of the Civil Registrar of
_____________ City, Philippines, my middle name was erroneously written as "CRUX"
instead of my true and correct middle name of "CRUZ";

2. That my true middle name is "CRUZ" as appearing in the same Certificate of Live as
the maiden name of my mother.

3. That in all pertinent documents which I had used, to include that of my scholastic
records (transcript of records), I used my true and correct middle name of "CRUZ";

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

foregoing facts and to explain the discrepancy in my Certificates of Live Birth, as
regards my true middle name.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________, at _____________,

Philippines.
 AFFIANT

(JURAT)