Republic of the Philippines )

Province of ________________ ) SS.

City/Municipality of _______ ) 
x- - - - - - - - - - - - - - - - - - - - - x

AFFIDAVIT OF RECONCILIATION OF BIRTH DATA

I, _______________________________, of legal age, single, Filipino citizen, and with

residence at ___________________________ after having been sworn in accordance with
law, do hereby depose and state that:

1. I was born to Spouses _______ and _________ of Calbayog City on May 10, 1976;

2. In the birth certificate which I obtained only recently, my family name is spelled

as "________________" instead of "_________________" to which I have I have been
used to as in my school records, SSS, BIR and other public documents. A copy of said
birth certificate which indicated my family name as "_______________" is hereto attached
for reference;

3.   The names _________________ and ___________________ belong to one and

the same person, the undersigned herein;

4. 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 on this _________ day

of ______________, 20 ______  in _______________________.

______________________
Affiant

SUBSCRIBED AND SWORN TO before me this _____ day of _________ at

________________ affiant exhibited to his/her competent evidence of identity by way of
_________________ issued on __________________ in _______________, Philippines.

Doc. No. _____

Page No. _____
Book No. _____
Series of _____.