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REPUBLIC OF THE PHILIPPINES

REGIONAL TRIAL COURT


National Capital Judicial Region
BRANCH ____
________________ CITY

January xx, 2020

ORDER OF PAYMENT

ATTY. ___________
Clerk of Court
Office of the Clerk of Court-Regional Trail Court
_______ City

SIR/MADAM:

Please accept the payment of ATTY. ________________, in the


amount of One Thousand Pesos (Php 1,000.00), Philippine Currency, as fine
for the late filing of Judicial Affidavit in Civil Case No.
________________________ pursuant to the Order issued by this Court
dated ____________________.

JUAN DELA CRUZ


Court Interpreter

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