Republic of the Philippines ]

City of ______________…..…. ] S.S.

AFFIDAVIT OF DISCREPANCY

(Date of Birth)

I, _____________________________________ , of legal age, Filipino citizen, single ,residing at

_____________________________________________________________________________________
_________, UNDER OATH, do hereby depose and state THAT:

1. I am a holder of a MISMO account with SRN no. _____________ by the MARINA Maritime
Industry;
2. My date of birth recorded and appearing in my aforesaid MISMO account is ______________
which is erroneous because my correct date of birth is ________________ as shown in my
driver's license, copy of which is here to attached as ANNEX A;
3. I have this affidavit executed to attest to the truth of the foregoing and for purposes of
reporting the same to the MARINA Maritime Industry so that my date of birth erroneously
recorded as _________________ can be corrected to _______________ and to request for a
replacement or correction of MISMO account and SRN number bearing my correct date of
birth.

IN WITNESS WHEREOF, I have here unto affixed my signature on this ___th day of
_______________ in _________________________________________________.

_______________________________________________

Affiant

SUBSCRIBED AND SWORN to before me on this ___th day of _________________in

____________________________Philippines. Affiant exhibited as evidence of identity driver's license.

NOTARY PUBLIC

Doc. No. ______;

Page No. ______;

Book No.______;

Series of 20____..