Republic of the Philippines )
City of ______ ) S.S.
x--------------------------x
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 ______;