Republic of the Philippines )

City of ______ ) S.S.

x--------------------------x

AFFIDAVIT OF INDIGENCY

I, _________________, of legal age, single/married/widow, Filipino citizen, and presently residing at _____________________, after having been duly sworn to in accordance with law, do hereby 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____________.

3. That I am executing this affidavit to entitle me to the desired legal services.

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 ___________ in ____________, _____________, Philippines, and I have read and translated the foregoing Affidavit in a dialect known and understood by him/her..

Public Attorney II

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of ______;