REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ALBAY ) S.S.

TABACO CITY )
x------------------------------------------x

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. 1234 pending
before Branch 67 of the Metropolitan Trial Court of Quezon City;

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 have hereunto set my hand this ____ day of ___________ 20____ in
____________, _____________, Philippines.

___________________________________
 Affiant

SUBSCRIBED AND SWORN to before me, this ____ day of __________ 20____, in the City of
__________________, by ___________________ with Passport No.________________ issued
on __________________ at _____________.

ATTY. ANTHONY CLARK A. GAPIDO

Notary Public Tabaco City
For the Province of Albay
Roll No. 83746
IBP OR No. 227570; June 13, 2022
PTR No. 8843533; July 13, 2022 at Tabaco City
MCLE: N/A (Newly Admitted to the Bar)
2nd Floor Coastal Building Rental, Purok 2,
Morales Street, San Roque,Tabaco City, 4511

Doc No.____;
Page No. 450;
Book No. 35 ;
Series of 2022