REPUBLIC OF THE PHILIPPINES Sandiganbayan

Quezon City ================================================================================

1. Judicial Records Division Ground Floor2. Statistics -do-3. Atty. Renato T. Bocar -do-4. Cashier -do-5. Atty. Renato T. Bocar -do-

Steps in Securing Clearance

Requirements1. Accomplished form with picture 1x12. Processing Fee - P100.00 (If by Mail attached Postal Money Order pay to SANDIGANBAYAN. Pleaseenclosed self addressed stamped envelope.)3. Affidavit of Denial (if with namesake)

================================================================================ Date : ATTY. RENATO T. BOCAR Executive Clerk of Court IV O f f i c e Sir: May I respectfully request for Clearance/Certificate in connection with my

(Purpose of clearance) [PLEASE WRITE LEGIBLY]

________________________________ Signature over Printed Name APPLICANT’S PERSONAL DATA: 1. Name:

(Complete Middle Name)

2. Residential Address:

4. Civil Status: 5. Date of Birth: 6. Place of Birth:

7. Tel. Number: 8. Cellphone No.: 9. E-mail address:

10. Sex : ( ) Male ( ) Female

(First Name) (Last Name)

3. Office/Office Address:

[This portion is for the Docket Section]

Sandiganbayan Commonwealth Avenue, Quezon City

Date:

A certain

of

was charged before the Sandiganbayan in Criminal/Civil/Case/s No./s

filed on for

said case/s

(Name of Accused)

(Office)

(Status of Case/s)

(Designation of Offense)

Note: As of this date and per records on file NELIA CASANO GALLONo Civil/Criminal cases has been filed SB Chief Judicial Staff Officeragainst Judicial Records Division

Note: Validity good for six (6) months only. [ P L E A S E W R I T E L E G I B L Y ] __________________________________________________________________________________________________ /eac Commonwealth Avenue, Quezon City, Website: sb.judicial.gov.ph; Tel. No. 951-4497