REPUBLIC OF THE PHILIPPINES) Province of____________________) S.S.

City/Municipality of_____________) x---------------------------------------x AFFIDAVIT OF DENIAL for NBI CLEARANCE I, ________________(name of affiant)____________, Filipino, of legal age, [single]/[married to _________(name of spouse)_________], and a resident of ___________________(address of affiant)_______________, after having been duly sworn in accordance with law, hereby depose and state: 1. That the NBI Main Office in Taft Ave., Manila has advised me that said Office could not issue the required clearance in view of the appearance of name similar to my name in NBI files involving in case/s filed against said person bearing names similar to mine; 2. That I am NOT the same person as one __________________ a.k.a. _________ who was charged under I.S. No.________ / Criminal Case No.______ before the __________________________ for the crime of __________; 3. That my middle name is ________________ and not _____________. 4. That I am executing this affidavit to attest to the foregoing facts and to deny categorically and specifically under oath that I am not the same person mentioned in the docket/files of NBI with the said derogatory/civil/criminal record/s; In view of the foregoing, I am requesting NBI Main Office in Taft Avenue, Manila to issue the appropriate NBI clearance in my favor. IN WITNESS WHEREOF, I have hereunto affixed my signature this ____th day of ____________ 20___ at ____________, Philippines. _________________________________ (Signature of Affiant over Printed Name)

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for _________(City/Province)____________ this ____th day of ____________ 20___. Affiant personally came and appeared with _____________(Competent Evidence of Identity)______ issued by the _________(Government Agency)______ on ___(date)__ at ________(place)_________, bearing his photograph and signature, known to me as the same person who personally signed the foregoing instrument before me and avowed under penalty of law to the whole truth of the contents of said instrument. Atty ___________________________________________ Notary Public Commission Serial No. ____________________________ Notary Public for _______(Province/City)______________ Until December 31, 20__ Office: ______________(address)____________________ Roll No. __________

Doc. No. ____ Page No. ____ Book No. ____ Series of 20__

IBP Lifetime Roll No. _________; __/__/__ ; _(Province)_ PTR No. _________ ; __/__/__ ; _(Province)_ MCLE Compliance Cert. No. __________; __/__/__