REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ALBAY ) S.S.

TABACO CITY )
x------------------------------------------x

AFFIDAVIT OF RECONCILIATION OF BIRTH

DATA

I, _______________________________, of legal age, single, Filipino citizen, and with

residence at ___________________________ after having been sworn in accordance
with law, do hereby depose and state that:
1. I was born to Spouses _______ and _________ of Calbayog City on May 10,
1976;
2. In the birth certificate which I obtained only recently, my family name is spelled
as "________________" instead of "_________________" to which I have I have
been used to as in my school records, SSS, BIR and other public documents. A copy
of said birth certificate which indicated my family name as "_______________" is
hereto attached for reference;
3. The names _________________ and ___________________ belong to one and
the same person, the undersigned herein;
4. That I am executing this affidavit in order to attest to the truth of foregoing
circumstances and for the purpose of setting the records straight and declaring that
____________________ and _________________________ refer to one and the
same person.

IN WITNESS WHEREOF, I have hereunto affixed my signature on this _________ day

of ______________, 20 ______ in _______________________.

_______________________________

Affiant

SUBSCRIBED AND SWORN TO before me this _____ day of _________ at

________________ affiant exhibited to his/her competent evidence of identity by way of
_________________ issued on __________________ in _______________,
Philippines.

ATTY. ANTHONY CLARK A. GAPIDO

Notary Public Tabaco City
For the Province of Albay
Roll No. 83746
IBP OR No. 227570; June 13, 2022
PTR No. 8843533; July 13, 2022 at Tabaco City
MCLE: N/A (Newly Admitted to the Bar)
2nd Floor Coastal Building Rental, Purok 2,
Morales Street, San Roque,Tabaco City, 4511
Doc No.____;
Page No. 450;
Book No. 35 ;