I N T E R V I E W S H E E T / CLIENT’S PROFILE Time In

(Service/
Office)

Region __________________
District Office _________________________ Time In
Date _________________________________________Assigned to: __________________________________ (Lawyer)
Control No.: ___________________________________ Referred by/Indorsed by:________________________
Referred to: __________________________________

Interviewer: _____________________________________
(Name & Signature) Public Attorney

Approved by: _________________________________

(Name & Signature) DPA / OIC-DPA
Time
Out
 Legal Advice Legal Documentation Representation in court/quasi-judicial bodies
Inquest/Legal Assistance  Mediation/ConciliationAdministration of oath
Others _________________________________________

CLIENT'S PERSONAL CIRCUMSTANCES (to be filled up by client/interviewee; if more than one client use another sheet of paper)

Name: _____________________________________ Age: ______ Gender/Sex: ________ Civil Status: _____________

Religion: ___________________________________
Citizenship: _________________________________
Address: ___________________________________
E-mail: _____________________________________
Individual Monthly Income: _____________________
Detained: Yes No 
Detained since: ______________________________
Educational Attainment: _________________________________
Language/Dialect: _____________________________________
Contact No.: __________________________________________
Spouse: _____________________________________________
Address of Spouse: ____________________________________
Contact No. of Spouse: _________________________________
Place of Detention: _____________________________________

Name: ______________________________________ Age: ______ Gender/Sex: ________ Civil Status: _____________

Address: ____________________________________ Contact No.: __________________________________________
Relationship to client: __________________________ E-mail: ______________________________________________

Criminal Civil Labor

Pls. specify: _____________________ _____________________ ____________________
Administrative Appeal
Pls. specify: _____________________ _______________________

Plaintiff Petitioner Defendant Respondent

OppositorAccused Others
Complainant/Victim of:
a)R.A. 9262 (VAWC) c)R.A. 9745 (Anti-torture Law) e)Agrarian Case
b)R.A. 9372 (Human Security Act) d)R.A. 9344 (CICL) f)Others

Children in Conflict with the Law Urban Poor

Age: __________ Please specify: ________________________
Women Client Rural Poor
Indigenous Group Please specify: ________________________
Please specify: ________________________ Refugees/Evacuees
Person with Disability (PWD) Senior Citizen
Type of Disability: ______________________ OFW a) Land-based Sea-based

Plaintiff/Complainant Oppositor/Others
Defendant/Respondent/Accused
NAME: _________________________________________ ADDRESS: ___________________________________________
_______________________________________________ _____________________________________________________

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___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

Title of the Case and Docket No.:

___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Court/Body/Tribunal:__________________________________________________________________________________________

Cause of Action/Nature of Offense: ______________________________________________________________________________

___________________________________________________________________________________________________________
Court/Body/Tribunal: _________________________________________________________________________________________

Income Tax Return Certification from Barangay Certification (DSWD) Others (payslips, etc.)

___________________________________
Party/Representative

Republic of the Philippines)

_______________________) S.S.

AFFIDAVIT OF INDIGENCY

I, ________________________________________________ of legal age,  single  married: to

____________________________________________________  widow  widower 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 net monthly 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 _____________________________________, Philippines.

_____________________________________
Signature of Affiant

SUBSCRIBED AND SWORNto before me this _________day of _________________________

20_______ in __________________________________________, Philippines, and I have read and
Translated the foregoing Affidavit to a dialect understood by the affiant.

FOSS.F.003/REV.0