REPUBLIC OF THE PHILIPPINES)

ANGELES CITY
)S.S.

AFFIDAVIT OF DISCREPANCY
I, (NAME), of legal age, Filipino, (single/married/widow) and a
resident of _______________________________, after having been duly
sworn to in accordance with law, depose and state THAT:
1. I was born on the __th day of the (Month), year to spouses
(mother) and (father);
2. I have been using the name SAM L. MILBY in all my documents
and transactions;
3. However, when I obtained a copy of my birth certificate, I
discovered that my surname appearing thereon was erroneously
written as "MELBY";
4. The names SAM L. MILBY and SAM L. MELBY refer to one and
the same person;
5. I execute this Affidavit of Discrepancy of Surname to attest to the
truth of the foregoing facts and to explain the discrepancy in my
birth certificate with regards my surname.
IN WITNESS WHEREOF, I have hereunto
this ___________________ in Angeles City, Philippines.

set

my

hand

____________________
Affiant
SSS ID No. _____________

SUBCRIBED
AND
SWORN
TO before
me
this ___________________ in _________________, Philippines, affiant
exhibiting to me his/her competent evidence of identity by way of
__________________
issued
at
______________
on __________________.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2016.