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 mothers 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 mothers actual maiden name is _____________, which should
have been the correct entry in said certificate as my mothers 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 18 th 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 ________________.