Republic of the Philippines )

Lucena, Quezon ) S. S.

AFFIDAVIT OF DISCREPANCY

I, MARJORIE RELLESIVA SUYAT, single, of legal age, Filipino citizen and resident
of Brgy. Rosario, Gumaca, Quezon, after having been duly sworn to in accordance with law,
depose and state:

1. That I habitually used MARJORIE RELLESIVA SUYAT as my true and correct full
name as evident in all my documents particularly in my Certificate of Live Birth;
2. That in my Philhealth ID No. 08-025556717-2 my middle name was erroneously
registered as RILLESEVA instead of RELLESIVA;
3. THAT, the errors committed in my Philhealth ID related to my middle name is due to
honest mistake, not intentional nor meant to commit fraud or to cause prejudice to any
third person or entity;

4. THAT, I execute this affidavit in order to attest to the foregoing narration of facts and to
explain the discrepancy in my middle name appearing my Philhealth ID from the one
appearing in my Certificate of Live Birth;

5. That I further execute this affidavit to declare that MARJORIE RELLESIVA SUYAT
and MARJORIE RILLESEVA SUYAT refer to one and the same person;

IN WITNESS WHEREOF, I have hereunto signed my name this 27 th day of September,

2023 at Lucena City, Quezon.

MARJORIE RELLESIVA SUYAT

Declarant

SUBSCRIBED AND SWORN to before me this 27 th day of September, 2023 at Lucena

City, Quezon affiant exhibited to me her National ID No. 2637-4594-1052-1351

Doc. No. 220 FRANCIS EDGARDO G. LAVARRO

Page No. 46 Notary Public
Book No. X Commission Expires: December 31, 2023
Series of 2023 Roll of Attorney No. 78537, May 13, 2022
IBP No. 252794;Dec. 23, 2022, Pasig City
PTR No. 3138402
Jan. 03, 2023, Lopez, Que.
MCLE Compliance No. Newly Admitted