REPUBLIC OF THE PHILIPPINES)

Province of____________________) S.S.

City/Municipality of_____________)
x---------------------------------------x
AFFIDAVIT OF DENIAL OF CRIMINAL CHARGE
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 NOT the same person as one __________________ a.k.a. _________ who
was charged under I.S. No.________ / Criminal Case No.______ before the
__________________________ for the crime of __________;
2. That my middle name is ________________ and not _____________.
3. That I have never been the subject of any criminal complaint, charge or proceeding
before any prosecutor or court;
4. That I am executing this Affidavit to certify or attest to the truth of the foregoing facts
and for purpose of denying that I am the ____________________
a.k.a._________________________ who is the subject of the aforementioned case in
the I.S. No.________ / Criminal Case No.______.
5. Further Affiant sayeth none.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of ____________
20___ at ____________, Philippines.

________________( Signature)_________________
(Affiants 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.

Doc. No. ____

Page No. ____

Atty ___________________________________________
Notary Public
Commission Serial No. ____________________________
Notary Public for _______(Province/City)______________

Book No. ____

Series of 20__

Until December 31, 20__

Office: ______________(address)____________________
Roll No. __________
IBP Lifetime Roll No. _________; __/__/__ ; _(Province)_
PTR No. _________ ; __/__/__ ; _(Province)_
MCLE Compliance Cert. No. __________; __/__/__