REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ___________________) SS.

MUNICIPALITY OF ___________________)
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AFFIDAVIT OF DISCREPANCY

I, ______________________, of legal age, Filipino, single, and a resident of Brgy.

________________________, after having been duly sworn to in accordance with
law, hereby depose and state:

1. That I was born on May 24, 1996 in ____________________ to Spouses

_______________ and _____________________;

2. That I have been known in our community as _________________________

and I have been using this name in all my public and private transactions;

3. That however, I discovered that my name appearing in my Form 137

Identification Card issued by Polytechnic College of La Union is
___________________ instead of ________________________, the latter
being my true and correct name. Attached is a copy of my Certificate of Live
Birth;

4. That the erroneous entry in my Form 137 Identification Card was just a result
of an honest mistake on the part of the person who caused its registration and
the person who prepared the said document;

5. I am executing this affidavit to attest to the truth of the foregoing facts and
circumstances for the purpose of CLARIFYING AND EXPLAINING the
above-mentioned discrepancy and for all legal intents and purposes it may
serve.

IN WITNESS WHEREOF, I have hereunto set my hand this __th day of June
2021, in the ________________________, Philippines.

___________________________
____
AFFIANT
ID.
NO.________________________

SUBSCRIBED AND SWORN to before me this __th day of June 2021, in the
________________________, Philippines.