REPUBLIC OF THE PHILIPPINES)
) S.S.
I, (Name), of legal age, Filipino, married and a resident of (Address), after having been duly sworn to in accordance with law, depose and state:
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 (Date) in (Place), Philippines.
(Name)Affiant
SUBCRIBED AND SWORN TO before me this (Date) in (Place), Philippines by (Name of Affiant) affiant exhibiting to me his Competent Evidence of Identity by way of Passport Identification(ID Number) issued on (Date) in(Place).
Notary Public
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 20__.