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__

[12CD]

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. __________; __/__/__