Republic of the Philippines

Fedigniltrgarr
Quezon City

REQUTRNMENTS STEPS IN SECT'RING CLEARANCE

1. Accomplished Form with lx1 picture
2. Affidavit of Denial (lf with namesake)
3. Processing Fee - P100.00 (lf filed by mail, please
Docket Section
t
Statistics Section
attach Postal Money Order payable to
SANDIGANBAYAN enclosed with self-addressed
I
Office of the ECC IV
stamped envelope T
4. Letter of authorization if filed through a Cashier
representative T
Office of the ECC IV

Date
ATTY. MA. TERESA S. PABTJLAYAN
Executive Clerk of Court IV
Sandiganbayan

Madam:

May I respectfully request for Clearance / Certificate in connection with my

O?fttcfffror.t rrrrfft Tttg tfiTror.rei. gfosc((mc,\) ucg
(purpose ofclearance)

over Printed Name

APPLICANT'S PERSONAT DATA: Print legibly. Mark appropriate boxes ffi with / ,-!,

Note: Please ski one after each name (those with 2 or more names
First Name: ? A \) L T R I s T ft il Date of Birth (mm/dd/yyw)
o3 /zs /nsz
Complete Middle Name D U e N Place of Birth cFoo crY
Last Name s ft T o E-mailAddress: Fqttl <fto tqrO @qrrqil . com
CivilStatus: f= single ill wiaow/widower Sex: B tvtate
A Married ffi Annulled ffi Female

Residential Address: 2'G Uffr, Mottot\l,TAtl.9f( ctar, 6P Telephone No.:

Office & Office Address rtgr,lc Atro(N€rts 0fFtG Mobile No.: y,tq gzg qzs
6flu htuDR, h.l qlu9rntCr,ot+lgiitNT o!
.,(ilAPfitr"fE,
(This portion is to be accomplished by the DOCKET Sectionr)
Date:

A certain
(Name of Accused)
of
(Office)
waschargedbeforetheSandiganbayaninCriminal/Civil/Case/s/No./sfiled
on for
(Designation of Offense)
said case/s
(Status of Case/s)
Note:
As of this date and per available records of this office, NO CRIMINAVCIVIVCASE/s has been filed against

(Complete Name)

SANDRA P. CALUGAY
Chief Judicial Staff Officer
Judicial Records Division