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PAO FORM No.

2010-6

REPUBLIC OF THE PHILIPPINES)


) Ss.

AFFIDAVIT OF DISCREPANCY

I, , Filipino, of legal age, single/married/widower/widow, and


a resident of , after having been duly sworn to in
accordance with law, depose and state, that:

1. I was born on to Spouses and

, on at as evidenced

by the certified true copy of my Certificate of Live Birth which is hereto attached as Annex
“A”;

2. Since I came to reason and up to the present, I have been using the name
in all my personal and business transactions, as well as in all of my
school records and diplomas from elementary up to college, my name was spelled as
;

3. On when I secured a copy of my birth certificate from


the National Statistics Office, I was surprised to learn for the first time that my name therein
was spelled as _;

4. The names and refers to me,


being one and the same person;

PAO Code Book 70 of 375


5. I am executing this Affidavit of Discrepancy to attest to the truth of the
foregoing facts and in support of my application for a Philippine Passport
with the Department of Foreign Affairs.

IN WITNESS WHEREOF, I have hereunto set my hand this day


of , at Manila,
Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this day


of , at
_, Philippines. The identity of the affiant is established by
his Philippine Passport No. , issued on .

NAME OF PUBLIC ATTORNEY


Public
Attorney
(Pursuant
to R.A.
9406)

PAO Code Book 70 of 375