Republic of the Philippines

Province of S.s.
City/Municipality of

AFFIDAVIT OF INDIGENCY

I, of legal age, single/married to

and residing at
and having been duly
sworn in accordance with law, 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 affixed my signature this day of

, 20 , in the City/Municipality of ,
Province of
.

Signature of Affiant

SUBSCRIBED AND SWORN to before me this day of ,

20 at
, and I have read and translated the foregoing
Affidavit in a dialect known and understood by him/her.

ATTY.
Public Attorney II
(Pursuant to R.A.
9406)