REPUBLIC OF THE PHILIPPINES)

____________________ ) S.S.

AFFIDAVIT OF DISCREPANCY

I, , of legal age, Filipino, and a resident of, having been duly sworn to
in accordance with law, hereby depose and state that:

1. I was born on in Manila, and was issued a Certificate of Live

Birth in which the surname was stated;

2. However, the said surname was corrected with my true

surname, as indicated on the lower portion of my Certificate of Live Birth,
stating: “.”

3. I have been using my true surname in all my pertinent records,

both private and government institutions.

4. For all legal intents and purposes, the names (as indicated in
my Certificate of Live Birth) refer to one and the same person.

5. I execute this Affidavit of Discrepancy to attest to the truth of

the foregoing circumstances and to explain the discrepancy in my
Certificate of Live Birth with regard to my true surname.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day

of _________, 2021, at _____________, Philippines.

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this __ day of

________, 2021 by the affiant who exhibited to me her, bearing the affiant’s
photograph and signature.

Doc. No. __;

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