REPUBLIC OF THE PHILIPPINES)

Province of____________________) S.S.

City/Municipality of_____________)
x---------------------------------------x
AFFIDAVIT OF DENIAL for NBI CLEARANCE
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 the NBI Main Office in Taft Ave., Manila has advised me that said Office could not
issue the required clearance in view of the appearance of name similar to my name in
NBI files involving in case/s filed against said person bearing names similar to mine;
2. 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 __________;
3. That my middle name is ________________ and not _____________.
4. That I am executing this affidavit to attest to the foregoing facts and to deny
categorically and specifically under oath that I am not the same person mentioned in the
docket/files of NBI with the said derogatory/civil/criminal record/s;
In view of the foregoing, I am requesting NBI Main Office in Taft Avenue, Manila to issue the
appropriate NBI clearance in my favor.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of ____________
20___ at ____________, Philippines.
_________________________________
(Signature of Affiant over 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. ____
Book No. ____
Series of 20__

Atty ___________________________________________
Notary Public
Commission Serial No. ____________________________
Notary Public for _______(Province/City)______________
Until December 31, 20__
Office: ______________(address)____________________
Roll No. __________

IBP Lifetime Roll No. _________; __/__/__ ; _(Province)_

PTR No. _________ ; __/__/__ ; _(Province)_
MCLE Compliance Cert. No. __________; __/__/__