Republic of the Philippines 

Province of Laguna S.s.

City of San Pablo 

AFFIDAVIT
Sinumpaang Salaysay

I, __________________________ of legal age, single/married to _______________________

Ako, nasa wastong gulang, binata/dalaga/kasal kay (pangalan ng asawa)
and residing at _____________________________ and having been duly sworn in accordance with
at nakatira sa Pagkatapos na manumpa ng naaayon sa

law, depose and say:

batas ay nagsasalaysay:

1. That I desire to avail of the free legal service of the Public Attorney’s Office.
Na nais kong kunin ang libreng serbisyong legal ng Public Attorney’s Office.

2. That my monthly net salary/income is P______________________.

Na ang aking buwanang suweldo/kita ay

3. That I am a person: [] with disability

Na ako ay taong: may kapansanan na __________________________________.
[] CICL Age: _________
Menor de edad na may kasong criminal Edad: _________
[] Member of Indigenous Group Tribe: _________
Miyembro ng katutubong pangkat/tribo na ________________.
[] Urban poor
[] Rural poor

4. That I am executing this affidavit to attest to my indigency and my qualification to avail of

the desired legal services of the PAO.
Na isinagawa ko ang salaysay na ito upang patotohanan na ako ay nabibilang sa mahirap na
sector ng lipunan at karapat-dapat na mabigyan ng libreng serbisyong legal ng PAO.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of ________2018,
SA KATUNAYAN NITO, AKING inilagda ang aking pangalan ngayong ika- ng
in the City of San Pablo, Province of Laguna.

________________________
Signature of Affiant
Pirma

SUBSCRIBED AND SWORN to before me this ____ day of _______, 2018 at San Pablo City
Laguna, and I have read and translated the foregoing Affidavit in a dialect known and understood by
him/her.

________________________
Administering Officer