AFFIDAVIT OF DISCREPANCY

            I, JUAN C. DELA CRUZ, of legal age, single, and a resident of Davao City, after
having been duly sworn to in accordance with law, hereby depose and say:

            That since I was young, I have been using the name “JOHNNY C. DELA CRUZ;”

That I am also known by my family and friends as “JOHNNY C. DELA CRUZ”;

That recently, I applied for membership with the Philippine Health Insurance Corporation
(PhilHealth) and as a requirement for such application, I was made to submit my Birth
Certificate;

That when I requested for a copy of my Birth Certificate from the National Statistics Office, I
was surprised that my name as reflected on the official document is “JUAN C. DELA
CRUZ” (A copy of the Birth Certificate is hereto appended as ANNEX “A” and forms an
integral part hereof);

That I attest that “JOHNNY C. DELA CRUZ” and “JUAN C. DELA CRUZ” is one and the
same person;

That from now on, I will be using my true and correct name, JUAN C. DELA CRUZ.

            That I am executing this affidavit in order to attest to the truth of the facts
aforementioned, and for any legal purpose this may serve.

            IN WITNESS WHEREOF, I have hereunto set my hand this this _____________ at
____________.

JUAN C. DELA CRUZ

                        Affiant
Witnesses:

                                                                                                                                               

SUBSCRIBED AND SWORN to before me this this _____________ at ____________,, affiant

exhibiting to me his PhilHealth ID No. ________________.

                                                                                   
Doc No. ___;                                                                           Notary Public
Page No. ___;                                                             
Book No. ___;                                                             
Series of _____.