REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ___________________) SS.

MUNICIPALITY OF ___________________)
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AFFIDAVIT OF DISCREPANCY

I, ______________________, of legal age, Filipino, single, and a resident of Brgy.

________________________, after having been duly sworn to in accordance with law,
hereby depose and state:

1. That I was born on May 24, 1996 in ____________________ to Spouses

_______________ and _____________________;

2. That I have been known in our community as _________________________ and

I have been using this name in all my public and private transactions;

3. That however, I discovered that my name appearing in my Form 137

Identification Card issued by Polytechnic College of La Union is
___________________ instead of ________________________, the latter being my
true and correct name. Attached is a copy of my Certificate of Live Birth;

4. That the erroneous entry in my Form 137 Identification Card was just a
result of an honest mistake on the part of the person who caused its
registration and the person who prepared the said document;

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

and circumstances for the purpose of CLARIFYING AND EXPLAINING
the above-mentioned discrepancy and for all legal intents and purposes
it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this __th day of June
2021, in the ________________________, Philippines.

_______________________________
AFFIANT
ID. NO.________________________

SUBSCRIBED AND SWORN to before me this __th day of June 2021, in

the ________________________, Philippines.