FORM NO.

42
Affidavit of Discrepancy

REPUBLIC OF THE PHILIPPINES)

PROVINCE OF) s.s
CITY OR MUNICIPALITY OF
AFFIDAVIT OF DISCREPANCY

1, MARIA JUANA DELA CRUZ, (personal circumstances of affiant), after having

duly sworn, depose and say, that:

1. I am the first child of Spouses Juan Dela Cruz and Maria

Dela Cruz; and was born on _______________ Copies of the Marriage Contract of my
parents and my Certificate of Live Birth are attached as Annexes "A" and "B".

2. It appears that in my Certificate of Live Birth my registered name is "Maria

Juana Dela Cruz"; and not "Ma. Juana Dela Cruz"

3. In all my documents, school records, and in all transactions with private and
government entities, I had been using the name Ma. Juana Dela Cruz.

4. I have executed the foregoing to attest to the fact that my true and correct name
is "MARIA JUANA DELA CRUZ"; and that "MARIA JUANA DELA CRUZ" and "MA.
JUANA DELA CRUZ refers to one and the same person; and for all legal intents and
purposes.
IN WITNESS WHEREOF, 1 have hereunto affixed my signature this__th day of
____________________at__________________

MARIA JUANA DELA CRUZ

(aka Ma. Juana dela Cruz)
Affiant
JURAT

(Signature and Seal of the Notary Public)

(FORM NO. 1)