Revised DOJ-BOC Form No.

BOARD OF CLAIMS
(R. A. No. 7309)
Department of Justice
Manila

Picture

APPLICATION
1. Name of Applicant : __________________________________________

2. Address (Residence) : __________________________________________

Telephone : __________________________________________

3. Business Address : __________________________________________

Telephone : __________________________________________

4. Date & Place of Birth : __________________________________________

5. Civil Status :__________________ Nationality : ________________________

6. Name of Spouse : __________________________________________

7. Name of Child / Children:

Name Date & Place of Birth Age

a.______________________________________________________________________
b.______________________________________________________________________
c.______________________________________________________________________
d.______________________________________________________________________
e.______________________________________________________________________

8. Nature of Claim: (Check appropriate box and attach documents indicated)

a. Unjustly accused, convicted and imprisoned but subsequently released by

virtue o judgment of acquittal.

( ) Certified True Copy of lowers court’s decision of conviction;

( ) Certified True Copy of appellate court’s decision of acquittal; and
( ) Certified True Copy of commitment order and released from
confinement by the jail warden or prison authority concerned.

b. Unjustly detained and released without being charged.

( ) Any proof to show that he was unjustly detained without being charged.
(e. g. such as records of arrest; detention and release.)

c. A victim of arbitrary or illegal detention by the authorities and defined in

the Revised Penal Code under final judgment of the court.
 (2)

d. Victims of Violent Crime:

( ) Certified True Copy of Police Report

(Spot and Casualty Report in case of KIA);
( ) Certified True Copy of Autopsy Report in case of Death;
( ) Certified True Copy of Doctor’s Medical Certificate
(for Serious Physical Injuries/Rape);
( ) Certified True Copy of Psychiatrist Certificate; if applicable; and
( ) Certified True Copy of Death Certificate and
( ) Medical Receipts, etc. (in case of Serious Physical Injuries)
( ) Certified True Copy of Resolution / Information (in case of Rape)
( ) For KIA, Certificate of Legal Beneficiaries / Declaration of Legal
Beneficiaries (Authenticated Copy)
( ) For WIA, Certificate (wounded) with journal (Authenticated Copy)

9. If claimant is an heir, he/she shall submit the following :

( ) Certified True Copy of Marriage Certificate if claimant is the spouse;

( ) Certified True Copy of Birth Certificate if claimant is a child/parent; or
( ) Proof of relationship that the claimant is the mother/sister/grandparent.
( ) Baranggay Certificate

Brief narration of incident giving cause of claim :

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
________

10. History of Claim :

a. I.S. Crim. Case No. :_________________________________________
b. Compainant :_________________________________________
c. Respondent/Accused:________________________________________
d. Nature of Offense :_________________________________________

Right thumb
mark
________________________
APPLICANT
(Signature over printed name)

SUBSCRIBED AND SWORN to before me this _____ day of_______________

2008, in the City of Manila, Philippines.

ADMINISTERING OFFICER
kayebongjanuary2008