Republic of the Philippines

Catbalogan City

)
) s.s.

AFFIDAVIT TO CORRECT DISCREPANCY IN FIRST NAME

I, , of legal age, married, Filipino and a resident of Catbalogan City, Samar, Philippines,
after having been duly sworn to in accordance with law, hereby depose that:
1. I am a legitimate child of _________of Catbalogan City, Samar;
2. I was born in Catbalogan City, Samar and my birth was recorded in the Local
Civil Registry thereat with my full name being entered as ____________as proved
by a copy of my Certificate of Live Birth issued by the National Statistics Office
(NSO);
3.

However, by mere inadvertence, and in good faith, I have been using the full
name, _________ in all my scholastic records instead of _______, the correct one;

4. I only learned that my real full name is ________ when I secured a copy of my
Certificate of Live Birth from the NSO in preparation for my application for my
Transcript of Records from Samar State University which is also required in order
to take the Nursing Board Examination;
5. I hereby declare, without any intent to mislead nor deceive the public, that I
______, and the person known by the full name, ______ refer to one and the
same person and henceforth I shall be using the full name _______ as it appears
in my Certificate of Live Birth; and
6. I have executed this affidavit to attest to the truth of the foregoing statements, for
the purpose of reporting the discrepancy in the way my first name is written, and
to effect the corresponding change thereon such that my correct first name may be
reflected in my records/documents and identification cards.
IN WITNESS WHEREOF, I have hereunto affixed my signature
_________________, in Catbalogan City, Philippines.

this

day,

__________
Affiant

SUBSCRIBED and SWORN to before me this day, ________________, in Catbalogan

City, Philippines, affiant being personally known to me.

Doc. No:
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Book No:
Series of 2014