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Republic of the Philippines)

City of Davao…………….)S.S


We, ________________________________, both of legal age, Filipino, and residents of

_______________________, Philippines, respectively, after having been sworn to in accordance
with law do hereby depose and state that:

1. That we personally know the person of _________________ who was born on

_____________________ at __________________________ to the spouses

2. That the date of birth of the aforementioned person as appearing in her Professional
Regulation Commission Record was erroneously entered as ________________________ while
in her PSA Certificate of Live Birth, it is entered as ________________________ which is true
and correct one;

3. That we could attest to the fact that ________________________ who was born on
____________________________ and ___________________________ who was born on
________________________ refers to one and the same person;

4. That the error is due to incorrect input of the date of birth by _________________________
when she applied for taking the examination online;

5. That no correction was made prior to the taking of the examination because
___________________________ only found out about the mistake after the examination when
she requested for her rating;

6. That the correction was made only after a lapse of time because _______________________
thought in good faith that she entered her correct date of birth through online application and
only found out about the mistake when she requested for her rating;

7. That this is the first time that a petition for change has been made by ______________________;

8. That we are not related either by affinity or by consanguinity and that we have no interest of
whatsoever with the above-mentioned persons;

9. That we are executing this affidavit to attest the truth of the foregoing averments.

IN WITNESS HEREOF, we have hereunto affixed our signatures this

__________________________ in the _______________________, Philippines.

Affiant Affiant

SUBSCRIBED AND SWORN to before me this ___________________________ in the

_____________________________, Philippines, Affiants personally known to me.

Doc. No._________
Page No._________
Book No. _________
Series of 2019.