REPUBLIC OF THE PHILIPPINES)

LINGAYEN, PANGASINAN ) SS

AFFIDAVIT

I, _______________, of legal age, single, Filipino citizen and a resident of

______________, after having duly sworn to in accordance with law, hereby depose and say
that:

1. ___________ and ___________ entered into a contract of marriage on ___________

at Our Lady of Lourdes Salasa Bugallon, Pangasinan. Attached herein is a copy of the
PSA Marriage Contract duly marked as Annex “A”;

2. On October 1, 1984, I was born at ___________ to Spouses ___________. A copy of

my NSO Certificate of Live Birth is attached herein as Annex “B”;

3. Recently however, I discovered that there is a discrepancy in my certificate of live

birth. Although my parents were married, my middle name was left blank or was
omitted and thus, my name indicated therein is only “___________” instead of
“___________”;

4. I am executing this affidavit to attest to the veracity of the foregoing facts and as a
requirement for the correction of my name in my certificate of live birth;

5. I am further executing this affidavit for whatever legal purpose it may serve under the
law.

IN WITNESS WHEREOF, I have hereunto set my hand this 23 rd day of June, 2020 in
Lingayen, Pangasinan.

___________
Affiant

SUBSCRIBED AND SWORN to before me this 23 rd day of June, 2020 in Lingayen,

Pangasinan.

___________