UNIVERSITY OF THE EAST LEGAL AID CLINIC

College of Law
2219 Recto Ave, Sampaloc, Manila, 1008 Metro Manila

NAME:

CONTACT NO:

ADDRESS:

BIRTHDAY:

AGE:

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SUBJECTS ALREADY TAKEN:

REASON WHY YOU WANT TO JOIN LEGAL AID SINUMPAANG SALAYSAY Ako, si ___________________,
walang asawa/may asawa, ____ taong gulang, kasalukuyang naninirahan sa _______________________,
pagkatapos makapanumpa ng naaayon sa batas, ay malayang nagsasaysay na: 1. Ako ay may
savings/time/current account deposit sa ____________________ Bank, _________________ Branch na
matatagpuan sa ______(ADDRESS)__. Ang nasabing deposito ay may Account No.
_________________________ at may balanseng nagkakahalaga ng _______________________ (Php
________) noong ________________. 2. (Isalaysay kung ANO ang insidenteng inirereklamo, KAILAN at
SAAN ito naganap) 3. (Isalaysay kung PAANO naganap ang insidente.) 4. (Kung kilala, isalaysay kung SINO
ang may kagagawan ng insidenteng inirerekklamo at ano ang posisyon niya sa Bangko.) 5. (Kung alam
din, isalaysay kung BAKIT naganap ang insidente) 6. (Kung mayroon, isalaysay kung sino-sino ang nakakita
sa insidente o kasama nang maganap ang insidente o makapagpapatunay nito.) 7. (If any, state the
documents that may prove the incident and attach copies thereof to the affidavit.) 8. I have not
commenced any action or filed any claim involving the same issues before the BSP or any court, tribunal
or quasijudicial agency and, to the best of my knowledge, no such other action or claim is pending
therein. (If there is a similar case or action, full disclosure of the status of the same should be done. The
following details should be provided: the court/tribunal/government agency where the action/claim is
filed; nature of action/claim; parties; date action/claim was filed; etc.) 9. If I should thereafter learn that
a similar action or claim has been filed or is pending before a court. tribunal or agency, I undertake to
report that fact within five (5) days therefrom to PDIC. 10. (Include only if the complaint involves a
deposit in the bank) By reason of the fact that my deposit with Account No. _____________ is involved
in this complaint, I am expressly authorizing PDIC and/or any of its duly-authorized representatives to
examine all the records of the said deposit account and secure copies thereof in accordance with the
exception provided for under Republic Act No. 1405 (Law on Secrecy of Bank Deposits). 11. I am
executing this affidavit to attest to the truth of the foregoing and for whatever legal purpose it may
serve. 12. At the moment, affiant further sayeth naught. 7. (Kung mayroon, sabihin kung
SINUMPAANG SALAYSAY Ako, si ___________________, walang asawa/may asawa, ____ taong gulang,
kasalukuyang naninirahan sa _______________________, pagkatapos makapanumpa ng naaayon sa
batas, ay malayang nagsasaysay na: 1. Ako ay may savings/time/current account deposit sa
____________________ Bank, _________________ Branch na matatagpuan sa ______(ADDRESS)__.
Ang nasabing deposito ay may Account No. _________________________ at may balanseng
nagkakahalaga ng _______________________ (Php ________) noong ________________. 2. (Isalaysay
kung ANO ang insidenteng inirereklamo, KAILAN at SAAN ito naganap) 3. (Isalaysay kung PAANO naganap
ang insidente.) 4. (Kung kilala, isalaysay kung SINO ang may kagagawan ng insidenteng inirerekklamo at
ano ang posisyon niya sa Bangko.) 5. (Kung alam din, isalaysay kung BAKIT naganap ang insidente) 6.
(Kung mayroon, isalaysay kung sino-sino ang nakakita sa insidente o kasama nang maganap ang insidente
o makapagpapatunay nito.) 7. (If any, state the documents that may prove the incident and attach copies
thereof to the affidavit.) 8. I have not commenced any action or filed any claim involving the same issues
before the BSP or any court, tribunal or quasijudicial agency and, to the best of my knowledge, no such
other action or claim is pending therein. (If there is a similar case or action, full disclosure of the status of
the same should be done. The following details should be provided: the court/tribunal/government
agency where the action/claim is filed; nature of action/claim; parties; date action/claim was filed; etc.)
9. If I should thereafter learn that a similar action or claim has been filed or is pending before a court.
tribunal or agency, I undertake to report that fact within five (5) days therefrom to PDIC. 10. (Include
only if the complaint involves a deposit in the bank) By reason of the fact that my deposit with Account
No. _____________ is involved in this complaint, I am expressly authorizing PDIC and/or any of its duly-
authorized representatives to examine all the records of the said deposit account and secure copies
thereof in accordance with the exception provided for under Republic Act No. 1405 (Law on Secrecy of
Bank Deposits). 11. I am executing this affidavit to attest to the truth of the foregoing and for whatever
legal purpose it may serve. 12. At the moment, affiant further sayeth naught. 7. (Kung mayroon, sabihin
kung

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