(Para sa iba ang pangalan sa NSO Birth Certificate at sa tunay na ginagamit.)
I, (Pangalan), Filipino, of legal age, with postal address at (Address), after having been sworn to in accordance with law, hereby depose and state:
1. That my name appearing in my Certificate of Live Birth issued by the National Statistics Office (NSO) is (“Pangalan”), as shown by a copy of the said document hereto attached as Annex “A”;
2. That however, I have been using the name (“Pangalan na laging ginagamit“), a copy of the said documents using such name are hereto attached as Annexes “B” and “C”.
(I-attach ang mga dokumentong nagpapatunay na dati mo pang ginagamit ang pangalan na iyan, e.g., driver’s license, SSS ID, school records, etc.)
3. That the names (“Pangalan sa Birth Certificate”) and (“Pangalan na ginagamit”) refer to one and the same person, which is the undersgined/affiant herein;
4. That I am executing this affidavit to attest to the truthfulness and veracity of the foregoing and for whatever legal purpose it may serve best.
IN WITNESS WHEREOF, I have hereunto affixed my signature this __th day of _________ 20___ in _________City.
Republic of the Philippines)
SUBSCRIBED AND SWORN to before me this ____ day of ___________ in _________City, with affiant exhibiting to me his/her __________________.
Doc. No. ____;
Page No. ____;
Book No. ____;
Series of 2009.