Republic of the Philippines )

) S.S.

AFFIDAVIT OF DENIAL

I, ___________________, of legal age, Filipino, (single/married/widow) and a resident of

_______________________________, after having been duly sworn to in accordance with law, depose
and state:

1. That I was born on ________________ in __________________________;

2. That I established my permanent residence in __________________, Philippines;

3. That on ___________________, I applied for a Record Clearance from the National Bureau of

Investigation;

4. That I received an information from the National Bureau of Investigation on ______________

that my namesake, a certain _______________________, has a pending criminal case for
Attempted Homicide docketed as Criminal Case No. ______ pending before Branch __ of the
___________________________;

5. That I hereby unequivocally deny involvement in the aforementioned case;

6. That I also declare under oath that I am not in any way involved in any case
proceeding as either plaintiff/complainant or defendant/accused in the Philippines
and abroad, specifically with regard to the aforementioned case;

7. That I have been employed or residing in Hong Kong for ________ years to this date;

8.That ___________________________________________________ (cite other proof/s or reason/s

to substantiate your claim that you are not involved in the aforementioned case/s, if any);
and

9. That I am executing this Affidavit to attest to the foregoing facts and to deny
absolutely and entirely any involvement in the case/s aforementioned and for all
legal intents and purposes.

IN WITNESS WHEREOF, I hereby affixed my signature this ___________________ in

_________________, Philippines.

____________________
Affiant
 SUBCRIBED AND SWORN TO before me this _____________ in ______________, Philippines,
affiant exhibiting to me his/her competent evidence of identity by way of ______________
issued at _____________ on ______________.
   

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 20___.