REPUBLIC OF THE PHILIPPINES)

MUNICIPALITY OF CARRASCAL ) S.S.

AFFIDAVIT OF DISCREPANCY IN SIGNATURES

I, TEODORO A. IRIZARI, of legal age, Filipino, married to PIGENIA R. IRIZARI,

and resident of P-1 Gamuton Carrascal, Surigao del Sur, after being duly sworn in
accordance with law, hereby depose and say:

1. That, I have caused the signing of my Philhealth I.D. with PIN: 18-200030254-6
and Voter’s I.D. with VIN: 6807-0029B-C0164PRI20001-0;

2. That, in the same manner, I have personally signed, with my wife, a Deed of
Voluntary Commitment (DVC) on December 29, 2017 using a different signature;

3. That, I acknowledge all specimen signatures and acts pertinent to signing as mine;

4. That, the said specimen in the DVC is the one that I have been using recently;

5. That, I execute this Sworn Statement to attest to the truth and veracity of the
foregoing set of facts, in connection with the requisites for adoption of our
grandchild, “SHAKIRA LADY GAGA IRIZARI”, pending in the Department of
Social Welfare and Development -Caraga, and for whatever legal purpose this may
serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _____ day of

_________________, at ___________________.

TEODORO A. IRIZARI
Affiant

SUBSCRIBED AND SWORN to before me this _______ day of

______________, at the ________________________, Philippines, the affiant
exhibiting to me his (Government) issued ID/ CTC with number _______________,
issued on ________________, in ______________________.

Doc. No. _______;

Page No. _______;
Book No. _______;
Series of 2018.