REPUBLIC OF THE PHILIPPINES )

CAGAYAN DE ORO CITY ) S. S.

AFFIDAVIT OF DISCREPANCY IN NAME

I, JUAN DELA CRUZ, of legal age, married, Filipino, and resident of

______________, after having taken oath in accordance with law, hereby depose and
say, to wit:

1. I am using the name of ____________________ as stated and registered in my

Certificate of Live Birth.
2. I got married to __________________ last ___________ in my Certificate of
Marriage, which indicates my birthday on ______________ instead of
_________________.
3. The name ____________________that born on ______________, and
_________________ born on _________________.
4. This affidavit is being executed to attest to the truth of the foregoing
statements, and for whatever legal purpose this may serve.

IN WITNESS HEREOF, I have hereunto affixed my signature this _________at the

City of Cagayan de Oro, Philippines.

JUAN DELA CRUZ

Affiant

SUBSCRIBED AND SWORN TO before me this __________ at the City of Cagayan

de Oro, Philippines.

Doc. No.____;
Page No.____;
Book No.____;
Series of 2021.