REPUBLIC OF THE PHILIPPINES)

Quezon City ) SS.

AFFIDAVIT OF DISCREPANCY IN NAME

 

I, ______ , of legal age, single, and with address at 6 Brgy. Pag-asa Q.C. , under oath, state that:

1. The birth certificate issued on February 11, 1997 at Civil Registrar Maasin Southern Leyte
indicates my name as ______. A copy of my birth certificate is hereto attached as ANNEX “A”;

2. On the other hand, in the passport issued to me on May 4, 2017 at Department of Foreign
Affairs NCR, my name is indicated as _______. A copy of the page of my passport where my
name and picture appears is hereto attached as ANNEX “B”;

3. That the name _____ and _________ refer to one and the same person, the herein Affiant;

4. That I am executing this Affidavit to attest to the truth of the foregoing facts and to use the
same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this ____day of September 2018 at

Quezon City.

___________________
Affiant

SUBSCRIBED AND SWORN to before me this _______________ at Quezon City, Affiant

exhibiting to me his ________ bearing No. ______________________________ issued at
______________ on _________________.

Doc No. ________;

Page No. _______ ;

Book No. _______;

Series of ________.