Republic of the Philippines)

S.S.
City of Manila )
AFFIDAVIT OF DENIAL
I,____________________., of legal age, single, former Filipino citizen,
now a nite! States citizen, an! a resi!ent of """""""""""""""""""""after
ha#ing been !uly sworn to in accor!ance with law, hereby !epose an! say$
%. &hat I am an applicant for 'ational (ureau of In#estigation )'(I)
clearance un!er Registry 'os.""""""""" an! """""""""""""""*
+. &hat the following criminal recor!s appear in the recor!s of the '(I
un!er my name$
, State criminal recor!s,
-. &hat the sai! recor!s !o not pertain to me*
.. &hat I e/ecute this affi!a#it to attest to the fact that I am not the same
person being referre! to in the foregoing recor!s of the 'ational (ureau of
In#estigation.
I' 0I&'1SS 021R13F, I ha#e hereunto affi/e! my signature this
"""!ay of 4uly +5%..
Affiant