REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI ) S.S.

x----------------------------x

AFFIDAVIT OF DISCREPANCY

I, SAM L. MILBY, 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 15th day of the October 1960 to spouses Anna Lerma and John Milby;

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” refers 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 set my hand this ____ day of ___________ 20____ in ____________, _____________, Philippines.

___________________________________

Affiant

SSS ID No. _____________

SUBSCRIBED AND SWORN to before me, this ____ day of __________ 20____, in the City of __________________, by ___________________ with Passport No.________________ issued on __________________ at _____________.

Notary Public

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of ______;