REPUBLIC OF THE PHILIPPINES

CITY OF ILOILO

AFFIDAVIT OF DISCREPANCY

I, EDWIN C. REFALBOR, of legal age, Filipino () and a resident of Brgy. Belen, Banate, Iloilo after
having been duly sworn to in accordance with law, depose and state THAT:

1. I was born on August 5, 1964;

2. I have been using the name EDWIN C. REFALBOR in all my documents and transactions;
3. However, when I obtained a copy of my CLOA, I discovered that my surname appearing
thereon was erroneously written as “REFALBER”;
4. The names “EDWIN C. REFALBOR” and “EDWIN C. REFALBER” refers to one and the same
person;
5. I execute this Affidavit of Discrepancy of Surname to attest to the truth of the foregoing facts
and to explain the discrepancy in my CLOA with regards my surname.

IN WITNESS WHEREOF, I have here unto set my hand this ____ day of _______________
in Iloilo City, Philippines.

EDWIN C. REFALBOR
Affiant
ID No. 11-200938010-0

SUBSCRIBED AND SWORN TO before me this ____________ in _______________, Philippines,

affiant exhibiting to me his/her competent evidence of identity by way of _______________
issued at __________ on _______________.

Doc. No. __________;

Page No. __________;
Book No. __________;
Series of ___________