Affidavit of Discrepancy

Introduction

I, [YOUR NAME], residing at [YOUR ADDRESS], hereby declare and affirm under penalty of perjury that the following statements are true and correct to the best of my knowledge and belief:

Statement of Facts

1. I am the individual identified on the birth certificate with the following details:

   • Name: [YOUR NAME]

   • Date of Birth: [YOUR BIRTH DATE]

   • Place of Birth: [YOUR BIRTH PLACE]

   • Father's Name: [YOUR FATHER'S NAME]

   • Mother's Name: [YOUR MOTHER'S NAME]

2. Upon reviewing my birth certificate issued by [ISSUING AUTHORITY NAME] on [ISSUANCE DATE], I have identified certain errors and discrepancies therein.

3. The errors identified in my birth certificate are as follows:

   • [DESCRIPTION OF DISCREPANCY]

4. The correct information that should be reflected on my birth certificate is as follows:

   • [CORRECTED INFORMATION]

5. I hereby request that the necessary corrections be made by [ISSUING AUTHORITY NAME] to my birth certificate to accurately reflect my personal information.

I, [YOUR NAME], affirm that the information provided herein is true, accurate, and complete to the best of my knowledge and belief. I declare under penalty of perjury under the laws of [STATE NAME] that the foregoing is true and correct.

Signature

[YOUR NAME]

Sworn to and subscribed before me this [DATE].

[NOTARY PUBLIC NAME]

[NOTARY PUBLIC COMMISSION NUMBER]

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