Republic of the Philippines )City of Santa Rosa ) S.S.

AFFIDAVIT OF DISCREPANCY APPEARING ON CERTIFICATE OF LIVE BIRTH

I, _______________, of legal age, single, Filipino citizen, and presently residing at Block 4 Lot 1 Phase II-A, Progressive Village, Brgy. Tagapo, City of Santa Rosa, Laguna, after having been duly sworn to in accordance with law, do hereby depose and say:

1. That my name is  _______________ as stated and registered in my Certificate of Live Birth issued by the office of the City of Civil Registry of San Pedro, Laguna, bearing the birthdate of July 8, 1994;

2. That my true middle name is ______________ as appearing on the same Certificate of Live Birth;

3. That said Certificate of Live Birth erroneously bears my mother’s maiden name as _______________, which is actually the name she acquired upon marriage with my father, thereby causing possible confusion as to my middle name;

4. That my mother’s actual maiden name is _____________, which should have been the correct entry in said certificate as my mother’s maiden name;

5. That in all pertinent documents that I have used, including those of my scholastic records, I have been using my true and correct middle name of ___________. That I am executing this affidavit to attest to the truth of all the foregoing facts and statements and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 18th day of August 2015 at the City of Santa Rosa, Laguna, Philippines.

_________________________                                                                                          Affiant                                                                             

            SUBSCRIBED AND SWORN to before me this 18th day of August 2015 in the City of Santa Rosa, Laguna, Philippines, the affiant exhibiting to me her ____________________________ issued at __________________________ on ________________.