Republic of the Philippines )

Lucena, Quezon ) S. S.

AFFIDAVIT OF DISCREPANCY

I, DOMINADOR TORCELINO TATEL, married, of legal age, Filipino citizen and

resident of Miramonte Subd., Tinamnan, Lucban, Quezon after having been duly sworn to in
accordance with law, depose and state:

1. THAT I was born on November 6, 1958 as evident in the record of the Local Civil
Registry Office of Virac, Catanduanes and I habitually used TORCELINO as my
middle name as evident in all of my documents, particularly in my PCN: 2583-9469-
0347-1206;

2. That in my PCN:2583-9469-0347-1206 my birthdate was erroneously registered as

November 6, 1957 instead of November 6, 1958, and in the Philhealth Record (HCI
Information ) my middle name was erroneously registered as TORCILINO instead of
TORCELINO;

3. THAT, the errors committed in my birthdate and in my middle name in the PCN: 2583-
9469-0347-1206 and in the Philhealth Record/HCI Information 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 birthdate and in my middle name appearing in my PCN:
2583-9469-0347-1206 and in my Philhealth Record/ HCI Information;

5. THAT, I further execute this affidavit to declare that my true and correct birthdate is
on November 6, 1958 and to declare that DOMINADOR TORCELINO TATEL and
DOMINADOR TORCILINO TATEL refer to one and the same person and as per
requirements of Philhealth for my benefits application and for whatever legal purpose it
may serve;

IN WITNESS WHEREOF, I have hereunto signed my name this 29 th day of

December, 2023 at Lucena City, Quezon.

DOMINADOR TORCELINO TATEL

Declarant

SUBSCRIBED AND SWORN to before me this 29th day of December, 2023 at

Lucena City, Quezon affiant exhibited to me his PCN: 2583-9469-0347-1206.

Doc. No. 250 FRANCIS EDGARDO G. LAVARRO

Page No. 51 Notary Public
Book No. XII 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