SAMPLE FORM

REPUBLIC OF THE PHILIPPINES)

Makati City                                 ) SS.

AFFIDAVIT OF DISCREPANCY

IN NAME

I, JUAN DE B. LA CRUZ,  of legal age, married, and with address at ______________________________________________________, under oath, state:

1.    THAT  my name is JUAN B. DE LA CRUZ  as stated and registered in my birth certificate issued by office of  the Civil Registry of ______________________. A copy of my birth certificate is hereto attached as ANNEX “A”;

2.    THAT the name JUAN B. DE LA CRUZ also appears in my passport which was issued based on the data appearing in my birth certificate. A copy of the  page of my passport where my name and picture appears is hereto attached as ANNEX “B”;

3.    THAT since childhood, my friends and acquaintances call me JOHN and thus since then I have been accustomed to using the name JOHN B. DE LA CRUZ in my personal records, transactions and communications;

4.    THAT the name JUAN B. DE LA CRUZ  and JOHN B. DE LA CRUZ refer to one and the same person, the herein Affiant;

5.    THAT I am executing this Affidavit to attest to the truth of the foregoing facts and to use the same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this _________________ at Makati City.

                                                                             JUAN B. DE LA CRUZ

                                                                                          Affiant

SUBSCRIBED AND SWORN to before me this _______________ at Makati City, Affiant exhibiting to me his Passport bearing No. ______________________________ issued at ______________ on _________________.

Doc No. ________;

Page No. _______ ;

Book No. _______;

Series of ________.

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