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 _____________ at ______________, Philippines.

______________
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of

___________ in _________, Philippines, and I have read and translated the
foregoing Affidavit in a dialectknown and understood by him/her..

Doc No. : _____

Page No.: ______
Book No.: ______
Series of
2014 Public Attorney II