REPUBLIC OF THE PHILIPPINES) Makati City ) SS.

AFFIDAVIT OF DISCREPANCY AFFIDAVIT OF DISCREPANCY IN NAME I, ______________________, 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 ______________________ 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 ______________________ and thus since then I have been accustomed to using the name ______________________ in my personal records, transactions and communications; 4. THAT name ______________________and ______________________CRUZ refer and the same person, the herein Affiant; to the one

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 ________.