REPUBLIC OF THE PHILIPPINES)

)Ss.

AFFIDAVIT OF DENIAL OF IDENTITY

I, , Filipino, of legal age, single/married/widow/widower, and

a resident of , after having been duly sworn to in
accordance with law, depose and state, that:

1. I am an applicant for a record clearance at the National Bureau of Investigation in

Manila, Philippines;

2. I learned that according to NBI records, a person without a middle name, but
bearing my same first and last names, had been convicted for the crime of by
the Regional Trial Court, Branch , in City, docketed as Criminal Case No.
;

3. I have not been charged of any criminal offense, and I therefore hereby declare
that I am not the same person named in the said criminal case;

4. I am executing this affidavit to apprise all those concerned of the foregoing facts
and for whatever other legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this day of

, at Manila, Philippines.
 Affiant

SUBSCRIBED AND SWORN to before me this day

of , at
, Philippines. The identity of the affiant is established by his
Philippine Passport No. _, issued on_ .

NAME OF PUBLIC ATTORNEY

Public
Attorney
(Pursuant
to R.A.
9406)