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Form No.4--Affidavit of Discrepancy Surname Family Name

(Affidavit of Discrepancy Surname Family Name)

Republic of the Philippines)
Province of__________________) S.S.
City/Municipality of____________)
x - - - -- - - - - - - x


I,JUAN DELA CRUZ, of legal age, married, Filipino and a resident of____________, Philippines having been duly sworn in accordance with law, hereby depose and state:

That on ____________, I was issued a Philippine Passport with passport number_____________in which my true surname DELA CRUZ was stated;

That before the expiration of the aforementioned passport on ___________, I had applied with Philippine Embassy in____________for the issuance of a new passport and on___________,I was issued a new Philippine passport with passport no.____________;

However, in the said new passport my surname had been erroneously misspelled as "DELA CRU" X

That I execute this Affidavit of Discrepancy to attest to the truth of the foregoing facts and to explain the discrepancy in my Philippine Passport with regards my surname.

IN WITNESS WHEREOF, I have hereunto set my hand this___________,at___________, Philippines.




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