INTERVIEW SHEET (For Legal Action/Assistance and Representation)

Time In
(Service/
Office):
_________

Region NCR Time In

(Lawyer):
District Office Mandaluyong _________
Date: _____________________________________ Action Taken:
Control No.: ______________________________  For further evaluation (merit and indigency test)
Time Out
 For legal representation and further legal assistance (Lawyer):
Assigned to: ____________________________________ _________
Interviewer: ATTY. SARITA A. DE JESUS  Legal assistance given: __________________________
Public Attorney  Others: _______________________________________
Referred by/Indorsed by: __________________________ Action approved by: ATTY. RENATO OLIVER A. RAMIREZ
Name & Signature of DPA/RPA/OIC
I. NATURE OF REQUEST (To be filled up by PAO personnel)
 Legal Documentation Administration of Oath Representation in Court/Quasi-Judicial Bodies
 Inquest Legal Assistance  Mediation/Conciliation Others: ______________________________
II. APPLICANT’S PERSONAL CIRCUMSTANCES
(To be filled up by applicant/representative; Use another sheet of paper if there’s more than one client)
Name: ___________________________________ Age: ______ Sex: ________ Civil Status:
Religion: Educational Attainment:
Citizenship: Language/Dialect:
Address: _________________________________ Contact No.: ________________________________
E-mail: Spouse:
Individual Monthly Income: Address of Spouse:
Detained: Yes No  Contact No. of Spouse:
Detained Since: Place of Detention:
II-A. REPRESENTATIVE’S PERSONAL CIRCUMSTANCES (To be filled up if the applicant is not present)
Name: Age: ______ Sex: ________ Civil Status:
Address: Contact No.:
Relationship to applicant: E-mail:

III. NATURE OF THE CASE

 Criminal  Civil  Labor
Administrative  Appealed

IV. APPLICANT’S CLASSIFICATION

 Child in Conflict with the Law  Senior Citizen  Foreign National:
 Woman VAWC Victim  Refugee/Evacuee  Urban Poor:
 Law Enforcer Drug-related Duty  Tenant in Agrarian Case  Rural Poor:
 OFW – Land-based  Arrested for Terrorism (R.A. No. 11479)  Indigenous People:
 OFW – Sea-based  Victim of Torture (R.A. No. 9745)  PWD; Type of Disability:
 Former Rebel (FR) and  Victim of Trafficking (R.A. No. 9208)  Petitioner for Voluntary Rehabilitation
Former Violent Extremist (FVE) (Drugs)

V. AFFIDAVIT OF INDIGENCY
Republic of the Philippines)
_____________________) S.c.
AFFIDAVIT OF INDIGENCY

I, _____________________________, of legal age, single married to: _______________________ widow/widower and residing at
__________________________________ and having been duly sworn in accordance with law, depose and say:

1. That I desire to avail of the free legal service of the Public Attorney’s Office;
2. That my monthly net salary/income is P_________________; and
3. That I am executing this affidavit to attest to the truth of the foregoing, and to entitle me to the desired legal services.

IN WITNESS WHEREOF, I hereby affix my signature this _______________ in Mandaluyong City, Philippines.

_________________________
Signature of Affiant
SUBSCRIBED AND SWORN to before me this ________________________ in Mandaluyong City, Philippines.

ATTY. SARITA A. DE JESUS

Public Attorney (Pursuant to R.A. No. 9406)

FOSS.F.003/REV.3 (effective 14 April 2023)

 VI. CONFLICT-OF-INTEREST REPRESENTATION
Would/do you agree that the adverse party will be/is represented by a lawyer from the Public Attorney’s Office (although from a different
District Office), in your case and any related case?
 Yes  No

Would/do you agree that the adverse party will be/is represented by a lawyer from the Public Attorney’s Office (same department of the
PAO: Special and Appealed Cases Service/Regional Special and Appealed Cases Unit) in the appeal or other mode of review of your case
and any related case?
 Yes  No

PLEASE ANSWER THE NEXT 2 QUESTIONS IF YOU ANSWERED “YES” TO BOTH QUESTIONS ABOVE

If you agree to the conflict-of-interest representation, do you understand that you are waiving your right to file any complaint against your
assigned Public Attorney and his/her immediate supervisor, or the opposing Public Attorney and his/her immediate supervisor, on the mere
basis and on mere allegations/suspicions of: (1) infidelity, double-dealing, or collusion with the other Public Attorney or opposing client/s; (2)
access to details about each other’s case, evidence, and legal strategy; (3) losing your case; (4) handling an unmeritorious case; (4) other
similar grounds indicating lack of confidence and trust to the assigned Public Attorney and his/her immediate supervisor?
 Yes, without condition or qualification

If you agree to the conflict-of-interest representation, do you still trust that your assigned Public Attorney and his/her immediate supervisor,
and agree that the adverse party’s Public Attorney and his/her immediate supervisor, shall handle their respective cases to the best of their
ability, with full fidelity to the cause of their respective clients, and shall be influenced by no other than the evidence on record?
 Yes, without condition or qualification
Full Name and Signature of Party/Representative
VII. PROOF OF INDIGENCY
For submission on or before _________________________
Income Tax Return Certification from Barangay Certification from DSWD  Others (payslips, etc.):
dated __________ dated __________ dated __________ _________________
____________________________________________
Full Name and Signature of Party/Representative
FOR LEGAL REPRESENTATION IN JUDICIAL AND QUASI-JUDICIAL CASES ONLY
(To be filled up by PAO Personnel; Write N/A if inapplicable)
VIII. APPLICANT’S CASE INVOLVEMENT

 Plaintiff  Defendant  Oppositor

 Petitioner  Respondent  Others:
 Complainant  Accused
VIII-A. ADVERSE PARTY
 Plaintiff/Complainant  Oppositor/Others
 Defendant/Respondent/Accused
Name: _______________________________ Address: ________________________________
VIII-B. FACTS OF THE CASE (Use separate sheet if necessary)

VIII-C. CAUSE OF ACTION/NATURE OF OFFENSE

VIII-D. PENDING IN COURT? YES NO

Title of the Case and Docket No:

Court/Body/Tribunal where pending:

FOSS.F.003/REV.3 (effective 14 April 2023)