REPUBLIC OF THE PHILIPPINES)

LIPA CITY, BATANGAS ) SS.

AFFIDAVIT OF DISCREPANCY IN BIRTH DATE

I, _________________________________, married, of legal age, Filipino, and with

residence address at Brgy. San Celestino, Lipa City, after having duly sworn in accordance with law
hereby depose and say that:

I am the same___________________________, born on _________________________in

Lipa City, Batangas. Copy of my Certificate of Live Birth is hereto attached and made part of
this affidavit;

I am a licensed professional teacher evidenced by a Professional Identification Card issued by

the Professional Regulation Commission (PRC), with Registration Number
_____________________. Copy of my PRC ID is hereto attached and made part of this
affidavit;

Regrettably, a discrepancy is found in my PRC registration records and PRC ID of my date of

birth written as__________________________, which is erroneous and should be corrected
as _________________________as my true and correct date of birth as evidenced by my
Certificate of Live Birth; and

I executed this affidavit to attest that my true and correct date of birth is
______________________ and to support my petition to change birthdate before the PRC.

IN WITNESS WHEREOF, I hereunto affix my signature this _____________________ at

Lipa City, Batangas.

_________________________
Affiant

SUBSCRIBED AND SWORN to before me this _______________ at Lipa City. Batangas.

Affiant exhibited to me her _____________________________________________________ as
competent proof of her identity.

NOTARY PUBLIC

Doc No. _______

Page No. ______
Book No. ______
Series of 2021