Republic of the Philippines

)
Province of Negros Occidental ) S.s
City of Sagay
)
X-------------------------------------X
AFFIDAVIT OF DISCREPANCY
I,
_____________________________, of legal age, Filipino,
married/single/widow/widower
and
a
resident
of
________________________________________________, after having been duly
sworn to in accordance with law, hereby depose and say that:
1.

That I am a native resident of __________________________ and have been

known and actually using ______________________________ which is my true
and correct name/date of birth/place of birth as appearing in my Birth Certificate
duly issued by the National Statistic Office;

2. That as per my school records duly issued by Philippine Normal University, and
my Marriage Certificate, it appears that the above-mentioned name is spelled as
____________________________________;
3.

That above stated records contains an erroneous entry as to the spelling of my

name as stated ______________________________, instead of
__________________________ which my true and correct name/date of
birth/place of birth;

4. That I am executing this affidavit for the purpose of establishing that my correct
name is ________________________, pursuant to my Birth Certificate and I
intent to cause the correction in the erroneous entry of my name with the
Philippine Normal University and with the St. Roch Parish, Brgy. Bato, Sagay
City, from ___________________________ to _____________________;
5.

That I attest to the truthfulness of the foregoing recording to the best of my

personal knowledge and belief.

IN WITNESS WHEREOF, I have hereunto

affixed my signature
__________________________ at Sagay City, Negros Occidental, Philippines.

this

____________________________
Affiant
CTC No.: ________________
Issued On. _______________
At Sagay City, Neg. Occ.
SUBSCRIBED AND SWORN to before me this ______________________ at
Sagay City, Negros Occidental, Philippines. Affiant exhibited to me her Community Tax
Certificate as shown under her respective name.
Doc. No. ______;
Page No. ______;
Book No. ______;
Series of _______.