PAO Form A Series of 2013

Provide Legal Advice

Prepare Legal Document
For Representation
For Mediation/Conciliation
For Judicial
For Non-Judicial
Others

Republika ng Pilipinas
KAGAWARAN NG KATARUNGAN

PUBLIC ATTORNEYS OFFICE

Caraga Region No. XIII
Cantilan District Office

Date
: ____________________________________
Control No.
: _____________________________________
Interviewer
: ____________________________________

Referred/Indorsed by: _______________________

Approved by:

Atty. Cashmere Jo-an Augustia D.

Zayas-Cruiz

(Name and Signature)

(Name and Signature)

DPA/OIC-DPA

I N T E R V I E W

S H E E T / C L I E N T S P R O F I L E

CLIENTS PERSONAL CIRCUMSTANCES

(to be filled up by client/interviewee; if more than one client, use another sheet of
paper)

Name
:_______________________________________ Age: ____ Gender: _____ Civil Status: ___________
Religion :_______________________________________ Educational Attainment: ______________________
Citizenship
:_______________________________________
Language/Dialect:_________ Occupation: ________
Address :_______________________________________ Contact No.:________________________________
E-mail
: ______________________________________ Spouse : __________________________________
Individual Monthly Net Income: _______________________ Address of Spouse: __________________________
Detained :
Yes
No
Contact
No.
of
Spouse
______________________
Detained since : ____________________________________
Place of Detention : _________________________

INTERVIEWEES PERSONAL CIRCUMSTANCES (if other than the client; to be filled up by interviewee)
Name
:_______________________________________ Age: _____ Gender: ________ Civil Status: _______
Address :_______________________________________ Contact No.: _______________________________
Relationship to Client :_______________________________
E-mail: ____________________________________
IA CLIENTS CASE INVOLVEMENT: (to be filled up by PAO Personnel )
Plaintif
Petitioner
Defendant Respondent
Others ____________________________________________
Complainant/Victim of:

a)
b)

R.A. 9262 (VAWC)

Accused

c)

R.A. 9745 (Anti-Torture Law) e)

d)

R.A. 9344 (CICL)

Case
R. A. 9372 (Human Security Act)

Oppositor

Agrarian
f)

Others

IB CLIENTS CLASSIFICATION: (to be filled up by PAO Personnel )

Children in Conflict with the Law
Age: _________________
Women Client
Indigenous Group
If yes, please specify:_______________
Person with Disability (PWD)

Urban Poor
If yes, please specify: _________________
Rural Poor
If yes, please specify: ____________________
Refugees/Evacuees
Senior Citizen Age:___________________________
OFW a)
Land-based
b)

Sea-

based
Type of Disability :__________________
II

ADVERSE PARTY
Plaintif / Petitioner / Complainant
Defendant / Respondent / Accused

Oppositor/Others

Name : ____________________________
Address : ____________________________________
_________________________________
__________________________________________
__________________________________
__________________________________________
III FACTS OF THE CASE: (to be filled up by Public Attorney) Use separate sheet if necessary
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
IV CAUSE OF ACTION / NATURE OF OFFENSE (to be filled up by PAO Lawyer)______________________________
____________________________________________________________________________________________________________
V

PENDING IN COURT?
Yes
No
Court / Body / Tribunal: ___________________________________
Title of the Case and docket no.: ________________________________________________________________

VI OTHER RELATED PENDING / CONCLUDED CASE(S): CAUSE OF ACTION / NATURE OF OFFENSE:

____________________________________________________________________________________________________________
Court / Body / Tribunal : _________________________________________________________________________
PROOF OF INDIGENCY SUBMITTED, IF ANY:
Income Tax Return
Certification from Barangay

Certification (DSWD

Others (Payslips, etc.,)

________________________________________
Party/Representative

Republic of the Philippines )

Municipality Of Cantilan__ ) s.s.
Province of Surigao del Sur )
x-----------------/

AFFIDAVIT OF INDIGENCY
I,_________________________________________________, of legal age,
single /
married to ____________________________________________ /
widow /
widower and residing at__________________________________
________________________________________________________
and
after
having been duly sworn to in accordance with law, hereby depose and
say:
1. That I desire to avail of the free legal services of the
Public Attorneys Office;
2. That my monthly net salary / income is Php__________;
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 _________________________ at _________________________,
Philippines.

_______________________
Signature of Affiant

SUBSCRIBED AND SWORN TO before me this ______ day of

___________ at _________________________, Philippines and I have read and
translated the foregoing Affidavit to a dialect understood by the affiant.

_______________________