Republic of the Philippines)

Province of___________________) S.S.

City/Municipality of___________)
x - - - - -- - - - - - x

AFFIDAVIT OF DISCREPANCY

I, MIRIAM ROBERTA C. CORNELIO, of legal age, Filipino, married and with

office address at Department of Agriculture, Elliptical Road, Diliman, Quezon City,
Philippines, having been duly sworn in accordance with law, hereby depose and state:

1. That in my Certificate of Live Birth as recorded in the Office of the

Civil Registrar of Pinili, Ilocos Norte, Philippines, my name was
erroneously written as "MIRIAM ROBERTA C. CORNELIO" instead of
my true and correct name of "MIRIAM CABUYADAO CORNELIO";

2. That in all pertinent documents which I had used, and in most of my

transactions, I have been using the name of MIRIAM CABUYADAO
CORNELIO since my early childhood;

3. It is only when I received the copy of my Certificate of Live Birth that I

discovered that name was erroneously written as "MIRIAM ROBERTA
C. CORNELIO";

4. That I am executing this Affidavit of Discrepancy to attest to the truth

of the foregoing facts and to explain the discrepancy in my Certificate
of Live Birth, as regards my true first name.

IN WITNESS WHEREOF,I have hereunto set my hand this___________, at___________,

Philippines.

MIRIAM ROBERTA C. CORNELIO

Affiant

SUBSCRIBED AND SWORN to before me this ____________________, affiant

exhibited to me his/her Competent Evidence of Identity by way of his ID
__________________ issued at _____________________________ on __________________.

Doc. No. ________

Page No. _______
Book No.________
Series of 2017.