REPUBLIC OF THE PHILIPPINES )

Province of ____________________ ) S.S.

City/Municipality of ______________ )
x---------------------------------------x
AFFIDAVIT OF RECONCILIATION OF BIRTH DATA
I, ________________(name of affiant)____________, Filipino, of legal age, [single]/[married to
_________(name of spouse)_________], and a resident of ___________________(address of
affiant)_______________, after having been duly sworn in accordance with law, hereby depose
and state:
1. That I am the [son]/[daughter] of the couple Mr. _________(name of
father)___________ and Mrs. ___________(name of mother)______________ and of
and I was born on __________(date of birth)__________ at ________________(place of
birth)________________;
2. That in the birth certificate which I obtained only recently, my [first name]/[middle
name]/[family name] is spelled as _______________ instead of _______________ to
which I have been used to as in my school records, SSS, BIR and other public
documents;
3. That a copy of said birth certificate which indicated my [first name]/[middle name]/
[family name] as ____________________ is hereto attached for reference. See Annex
A;
4. That a copies of my school records, SSS/GSIS, BIR and other public documents which
indicated my [first name]/[middle name]/[family name] as ____________________ is
hereto attached for reference. See Annex B, C, D, and E;
5. That the names belong to one and the same person, the undersigned affiant herein;
6. That I am executing this affidavit in order to attest to the truth of foregoing
circumstances and for the purpose of setting the records straight and declaring that
_________________ and _________________ refer to one and the same person.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of __________,
20__ , Philippines.
_________________________________
(Signature of Affiant over Printed Name)

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for

_________(City/Province)____________ this ____th day of ____________ 20___.
Affiant personally came and appeared with _____________(Competent Evidence of
Identity)______ issued by the _________(Government Agency)______ on ___(date)__
at ________(place)_________, bearing his photograph and signature, known to me as the
same person who personally signed the foregoing instrument before me and avowed
under penalty of law to the whole truth of the contents of said instrument.
Atty ___________________________________________
Notary Public

Doc. No. ____

Page No. ____
Book No. ____
Series of 20__

Commission Serial No. ____________________________

Notary Public for _______(Province/City)______________
Until December 31, 20__
Office: ______________(address)____________________
Roll No. __________
IBP Lifetime Roll No. _________; __/__/__ ; _(Province)_
PTR No. _________ ; __/__/__ ; _(Province)_
MCLE Compliance Cert. No. __________; __/__/__

NOTE: This affidavit is used to explain the discrepancy of the birth certificate against other
documents such as School Record, BIR, GSIS/SSS, etc.