Republic of the Philippines )

____________ )s.s.

AFFIDAVIT OF DISCREPANCY

I, Dragon, of legal age, married, Filipino and a resident of dragon lair, after
having been duly sworn to in accordance with law, hereby depose and state that:

1. I was born at the dawn of time at Caloocan City, Metro Manila to the Spouses
x and y. Attached is a photocopy of my Certificate of Live Birth issued by the
National Statistics Office (NSO) as Annex “A”.

2. However, when I applied for and I filled up the application form issued in my
favor by the Social Security System (SSS), I entered my name as Dragon,
instead of Grendel, the former being my married name, and the latter being
my true and correct maiden name;

3. The discrepancy is due to my separation from my husband since year 2000.

4. Therefore, the names Dragon and Grendel, pertain to one and the same
person, that is me and to no other;

5. I had never been charged criminally, civilly or administratively, much less,

convicted in any court, tribunal or government agencies, either in the
Philippines or abroad;

6. I am executing this affidavit in order to attest to the truth of the facts afore-
stated and to justify the use of this affidavit for whatever legal intents and
purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

______________________ at ___________________________________.

Dragon
Affiant

SUBSCRIBED AND SWORN to before me this ________________ at Clark

____________________, Affiant exhibiting to me her PhilHealth ID no. 07-
zzzzzzzzzz.

Notary Public

Doc No. ______

Page No. ______
Book No. ______
Series of 2018.