Republic of the Philippines )

Lucena, Quezon ) S. S.

AFFIDAVIT OF DISCREPANCY

I, PURIFICACION DAYAWON LUCABA, married, of legal age, Filipino citizen and

resident of Prk. Langka II, Mayao Crossing, Lucena City, Quezon Quezon, after having been
duly sworn to in accordance with law, depose and state:

1. That I am the daughter of ESTRELLA BELLEN DAYAWON who was born on

February 18, 1949 and died on October 23, 2023 at Quezon Medical Center- Lucena
City, Quezon;

2. That I personally know that the aforesaid ESTRELLA BELLEN DAYAWON

habitually used ESTRELLA as her first name as evident in all her documents particularly
in his Certificate of Marriage;

3. That in the Philhealth Benefit Eligibility Form her first name was erroneously registered
as ESTERILLA instead of ESTRELLA;

4. THAT, the errors committed related to her first name is due to honest mistake, not
intentional nor meant to commit fraud or to cause prejudice to any third person or entity;

5. THAT, I execute this affidavit in order to attest to the foregoing narration of facts and to
explain the discrepancy in the first name of ESTRELLA BELLEN DAYAWON
appearing in her Certificate of Marriage and from the one appearing in the Philhealth

6. Benefit Eligibility Form;

7. That I further execute this affidavit to declare that ESTRELLA BELLEN DAYAWON
and ESTERILLA BELLEN DAYAWON refer to one and the same person;
23rd
IN WITNESS WHEREOF, I have hereunto signed my name this day of October,
2023 at Lucena City, Quezon.

PURIFICACION DAYAWON LUCABA

Declarant

SUBSCRIBED AND SWORN to before me this 23 rd day of October, 2023 at Lucena

City, Quezon affiant exhibited to me her VIN: 5624-0563A-L0480PDL20000-6.

Doc. No. 36 FRANCIS EDGARDO G. LAVARRO

Page No. 9 Notary Public
Book No. XI 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