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
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]
Upon reviewing my birth certificate issued by [ISSUING AUTHORITY NAME] on [ISSUANCE DATE], I have identified certain errors and discrepancies therein.
The errors identified in my birth certificate are as follows:
The correct information that should be reflected on my birth certificate is as follows:
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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