Republic of the Philippines )

………………………………………. ) S.S.

AFFIDAVIT OF DISCREPANCY

I, XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX, of legal age, and currently residing at Barangay

Puting Bato, City of Calaca, Batangas, after being duly sworn, hereby depose and state as
follows:

1. My married name is XXXXXXXXXXXXXXXX. My maiden name registered is

“XXXXXXXXXXXXXXXXXXXXXXXX” on DecemberXXXXXXXXXXXX, as indicated in my
Certificate of Live Birth, issued by the Philippine Statistic Office;

2. That I am a holder of Passport No. XXXXXXXXXXXXXXXXX, issued by the Department of

Foreign Affairs, bearing my married name XXXXXXXXXXXXXXXXX which was issued on
XXXXXXXXXXXXXXX;

3. There is a discrepancy between my first name recorded in my birth certificate, which

states "DXXXXXXXXXXXN," and the first name stated in my passport, which indicates
"DXXXXXXXXXXXXXYN”;

4. I hereby affirm that the maiden name "XXXXXXXXXXXXXXXX" and the married name
"XXXXXXXXXXXXXXXX” pertain to one and the same individual.

5. I undertake full responsibility for the accuracy of the information provided in this
affidavit.

6. I am executing this Affidavit to attest to the truth of the facts and explain the
discrepancy in the Certificate of Live Birth concerning my maiden name and my married
name in other government-issued identifications.

7. I declare under penalty of perjury that the foregoing is true and correct to the best of my
knowledge and belief.

IN WITNESS THEREOF, I hereunto set my hand this _____________________ in

XXXXXXXXXXXXXX.

XXXXXXXXXXXXXX
Philippine Passport No. XXXXXXXXXXX

SUBSCRIBED AND SWORN TO before me this ______________________ in XXXXXXXXX

PHILIPPINES, affiant exhibited to me her government identity, as stated above.

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