REPUBLIC OF THE PHILIPPINES )

Province of ____________________ ) S.S.

City/Municipality of ______________ )
x---------------------------------------x

AFFIDAVIT OF RECONCILIATION OF BIRTH DATA

I, ________________(name of affiant)____________, Filipino, of

legal age, [single]/[married to _________(name of
spouse)_________], and a resident of
___________________(address of affiant)_______________, after
having been duly sworn in accordance with law, hereby depose and
state:

1. That I am the [son]/[daughter] of the couple Mr.

_________(name of father)___________ and Mrs.
___________(name of mother)______________ and of and I
was born on __________(date of birth)__________ at
________________(place of birth)________________;

2. That in the birth certificate which I obtained only recently, my

[first name]/[middle name]/[family name] is spelled as
“_______________” instead of “_______________” to which I
have been used to as in my school records, SSS, BIR and
other public documents;

3. That a copy of said birth certificate which indicated my [first

name]/[middle name]/[family name] as
“____________________” is hereto attached for reference.
See Annex A;

4. That a copies of my school records, SSS/GSIS, BIR and

other public documents which indicated my [first name]/[middle
name]/[family name] as “____________________” is hereto
attached for reference. See Annex B, C, D, and E;

5. That the names belong to one and the same person, the
undersigned affiant herein;

6. That I am executing this affidavit in order to attest to the truth

of foregoing circumstances and for the purpose of setting the
records straight and declaring that _________________ and
_________________ refer to one and the same person.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

____th day of __________, 20__ , Philippines.

_________________________________
(Signature of Affiant over Printed Name)

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for

_________(City/Province)____________ this ____th day of ____________
20___. Affiant personally came and appeared with _____________(Competent
Evidence of Identity)______ issued by the _________(Government
Agency)______ on ___(date)__ at ________(place)_________, bearing his
photograph and signature, known to me as the same person who personally
signed the foregoing instrument before me and avowed under penalty of law to
the whole truth of the contents of said instrument.

Atty _______________________________________
Notary Public
Doc. No. ____ Commission Serial No. __________________
Page No. ____ Notary Public for ______(Province/City)______
Book No. ____ Until December 31, 20__
Series of 20__ Office: ___________(address)_____________
Roll No. __________
IBP Lifetime Roll No. ________; __/__/__ ; (Province)
PTR No. _________ ; __/__/__ ; _(Province)_
MCLE Compliance Cert. No. __________; __/__/__

NOTE: This affidavit is used to explain the discrepancy of the birth certificate against other
documents such as School Record, BIR, GSIS/SSS, etc.
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