BOARD OF CLAIMS

(Republic Act No. 7309) Recent

Department of Justice Photo
Manila

APPLICATION
1. Name of Applicant: ____________________________________ Sex: __________
2. Date and Place of Birth: ________________________________ Age: __________
3. Address: ___________________________________________________________
4. Tel. / Cell No._________________________________ Nationality: ____________
5. E-mail Address: _____________________________________________________
6. ID presented: _______________________________________________________

** IF MINOR / DISABLED:
Assisted by : ________________________________________________________
Relationship to Applicant:

Spouse Son / Daughter Parent Brother/Sister

Grandparent Uncle/Aunt Social Worker Others ________

Address: _____________________________________________________________
Tel. / Cell No.: ________________________________________________________
E-mail Address: _______________________________________________________
ID presented: ________________________________________________________

7. Civil Status : Single Married Others

8. Name of Spouse ______________________________________________________
9. Name of Child / Children (Pangalan ng mga Anak): (if applicable)

Name Date Birth Age

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

10.History of Claim :
A. Prosecution Office where the case is filled: _________________________
B. Docket No. / I.S. No. / Criminal Case No.: _________________________
C. Complainant : ________________________________________________
D. Repondent / Accused: __________________________________________
E. Offense Committed: ___________________________________________
F. Date of Commission of Offense: __________________________________
G. Place of Commission of Offense: _________________________________

The Applicant undertakes to inform the Board of Claims of any change in the address and
contact number given above.
If Minor / Disabled,
Assisted by: ________________________
Signature over Printed Name Right Thumbark
APPLICANT Applicant
____________________________
Signature over Printed Name

SUBSCRIBED AND SWORN to before me this _____ day of _________ 20___, in the
City of _________, Philippines.

ADMINISTERING OFFICER