Republic of the Philippines ]

City of ______________…..…. ] S.S.

AFFIDAVIT OF DISCREPANCY

(Date of Birth)

I, JAN KATHERINE BALITBIT BAUTISTA , of legal age, Filipino citizen, single ,residing at Blk 15 Lot
4 Phase 4 Fairgrounds Vallejo Place, Pasong Buaya 2, Imus City, Cavite ,Philippines, UNDER OATH, do
hereby depose and state THAT:

1. I am a holder of a MISMO account with SRN no. 9804220119 by the MARINA Maritime
Industry;
2. My date of birth recorded and appearing in my aforesaid MISMO account is APRIL 22, 1998
which is erroneous because my correct date of birth is APRIL 29, 1998 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 APRIL 22, 1998 can be corrected to APRIL 29, 1998 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 12th day of May in Imus
City, Cavite Philippines.

JAN KATHERINE BALITBIT BAUTISTA

Affiant

SUBSCRIBED AND SWORN to before me on this _____day of _________________in

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

NOTARY PUBLIC

Doc. No. ______;

Page No. ______;

Book No.______;

Series of 20____..