Republic of the Philippines )

Province of ______ ) S.S.

AFFIDAVIT OF DISCREPANCY IN NAME

I, _______________________, of legal age, married, and with address at

______________________________, under oath, state:

1. THAT my name is ______________________ as stated and registered in my birth

certificate issued by Office of the Civil Registry ____________________. A copy of my
Birth Certificate is hereto attached as ANNEX “A”;

2. THAT the name ___________________ also appears in my

__________________________. A copy of my _______________ is hereto attached as
ANNEX “B”;

3. THAT since childhood, my friends and acquaintances call me __________________and

thus since then I have been accustomed to using the name ____________________ in
my personal records, transactions and communications;

4. THAT the name _______________ and ________________ refer to one and the same
person, the herein Affiant;

5. THAT I am executing this Affidavit to attest to the truth of the foregoing facts and to use
the same for whatever legal purpose it may serve best.

IN WITNESS WHEREOF, I hereunto affix my signature this _________________ at San

Miguel, Bohol, Philippines.

____________________________
Affiant

SUBSCRIBED AND SWORN to before me this _______________ at __________________,

with the Affiant exhibiting to me her Community Tax Certificate/Valid ID.

Doc No. ________;

Page No. _______ ;
Book No. _______;
Series of 2021