REPUBLIC OF THE PHILIPPINES)

PROVINCE OF LAGUNA ) S.S.

MUNICIPALITY OF PAETE )
x-----------------------------------------x

AFFIDAVIT OF DISCREPANCY IN NAME

I, TERESITA KAGAHASTIAN ROXAS, of legal age, married and with residence address at
A. Roces St. Brgy. 9-Ibaba del Norte Paete, Laguna under oath, state:

1. That in my Certificate of Live Birth, as recorded in the Office of the Civil Registrar of
Paete, Laguna, my name is written as “TERESITA CAGAHASTIAN ROXAS”
as stated and registered in my birth certificate issued by the Office of the
Municipal Civil Registrar. A copy of my birth certificate is hereto attached as
ANNEX “A”;

2. That I am the daughter of CLARO ADEFUIN ROXAS and FELOMINA SALCEDA

KAGAHASTIAN;

3. That my mother’s name is FELOMINA SALCEDA KAGAHASTIAN;

4. That the names FELOMINA S. KAGAHASTIAN and FELOMINA S.

CAGAHASTIAN refer to one and the same person;

5. That since childhood, my middle name has been used as KAGAHASTIAN and it was
the same name written in my important documents and valid ID’s;

6. That the names “TERESITA KAGAHASTIAN ROXAS” and “TERESITA

CAGAHASTIAN ROXAS” refer to only one and the same person, and that the
discrepancy may just be a mistake committed by the person who supplied the
information;

7. That I am executing this Affidavit of Discrepancy to attest to the truth of the

foregoing facts and for all legal purposes this may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this _____________________

in Paete, Laguna.

TERESITA KAGAHASTIAN ROXAS

Affiant
________________________

SUBSCRIBED AND SWORN to before me this _________________ in Paete,

Laguna. Affiant exhibiting to me his Valid ID as indicated above below her name.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of ____. ATTY. LAURENCE L. PASIA
Notary Public
Until June 30, 2021 per B.M. No. 3795
P. Gomez St. Brgy. Bangkusay
Paete, Laguna
IBP O.R. No. 145414
PTR No. 8545472
TIN 262-169-812
Attorney’s Roll No. 66146
MCLE Compliance No. VI- 0005190
Valid until April 14, 2022