REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ILOCOS NORTE )

CITY OF LAOAG ) S.S

AFFIDAVIT OF DISCREPANCY

I, NAME, of legal age, Filipino citizen, single, and a resident of Brgy. Garreta,
Badoc, Ilocos Norte, after being sworn to in accordance with law, do hereby depose
and say:

1. That the Philhealth identification card issued to me states that my complete

name is NAME and my date of birth is November 1, 1983;

2. That my birth certificate secured from the PSA provides that my complete name
is NAME without a middle name and my date of birth is November 1, 1981;

3. That NAME born on November 1, 1981 and ALMA GAMATERO DUCO born on
November 1, 1983 is one and the same person;

4. That this affidavit is intended to rectify the error in my name and date of birth in
the database of Philhealth;

5. That I am executing this affidavit to attest to the truth and veracity of the
foregoing facts.

IN WITNESS WHEREOF, I have hereunto set my hands this

________________ in the City of Laoag, Ilocos Norte, Philippines.

NAME
Affiant
Philhealth ID No. 05-201642707

SUBSCRIBED AND SWORN to before me this ________________ at Laoag

City, Ilocos Norte.

ATTY. FRANCIS RAUL L. DAYO

Notary Public for Ilocos Norte and Laoag City
Until June 30, 2021 / Notarial Com. No. 2018-35
Roll No. 67463 / MCLE Compliance No. VII-0001271
PTR No. 2197051 - L.C.1/06/2021 / IBP LIFETIME NO. 0990899
677-2283 / 0918-490-2274 / TIN 925-051-505-000

Doc. No. ______;

Page No. ______;
Book No. VIII;
Series of 2021.