Republic of the Philippines

__________________________
7th Judicial Region
Branch ______, _______ City

THE PEOPLE OF THE PHILIPPINES,

Plaintiff,
CRIM. CASE NO.
-versus- _____________

_________________________, For: ____________

Accused.
x---------------------------------------------/

APPLICATION FOR PROBATION

The undersigned accused, ___________________________________

a petitioner for probation under the provisions of PD 968 as amended, hereby
declares:

1. That Petitioner is _______ years of age,

single/married/widow/widower and a resident of
________________________________________________________;

2. That Petitioner has been convicted of

__________________________________ and sentenced to serve a term of
imprisonment of not more than six (6) years or to pay a fine of not more than
One Thousand Pesos (1,000.00) with subsidiary imprisonment in case of
insolvency;

3. That Petitioner has not begun to serve the term of imprisonment

imposed nor paid the fine imposed;

4. That the crime of which Petitioner has been convicted is not an

offense against the national security;

5. That Petitioner has not previously been convicted by final judgment

of any offense punished by imprisonment of not more than six (6) months and
one (1) day or a fine of not more than one thousand pesos (1000.00); and

6. That Petitioner has not been once on probation under the provisions
of PD 968 as amended.

(date) (place)

_________________
Signature of Applicant