REPUBLIC OF THE PHILIPPINES

KAGAWARAN NG KATARUNGAN
PUBLIC ATTORNEY'S OFFICE
TANGGAPAN NG MANANANGOL PAMBAYAN
Region: C A R
Regional office [ ] Baguio City District [ ]

District Office:

INTERVIEW SHEET
Date :
_________________
Control No. _________________
Ref. No.
_________________

Assigned to: ________________________________

Instructions: [ ] Advise _____________________
[ ] Prepare Pleading ____________
[ ] ____________________________

Unit Head: OIC, RPA Henry M. Francisco [ ] ______________

DPA, Honorio M. Sagsago
[ ] ______________
Interviewee/Clients:
Plaintiff

Petitioner

Oppositor

Defendant

Respondent

Accused
Others

[
[

]
]

R.A. 9262 (VAWC)

R.A. 9372 (Human Security Act

[
[

Children in Conflict with the Law

Age __________________

Women Client

Indigenous Group
If Yes, pls. Specify:
____________________________

Person with Disability

Type of Disability
____________________________

Complainant/Victim [
]
]
R.A. 9745 (Anti-Torture Law)
]
R.A. 9433 (CICL)

Client's Personal Circumstances:

Name:___________________________________
Address: _______________________________
E-mail:__________________________________
Individual Montly Net Income: _____________
Detained:
YES [ ] NO [ ]
Detained Since: __________________________
II

III

IV
V
VI

Adverse Party:
[ ] Plaintiff/ Petitioner/Complaint
[ ] Defendant/Respondent/Accused

[
[

]
]

[ ] Urban Poor
If yes, Pls. specify:
________________________________
[ ] Rural Poor
If yes, Pls. specify:
________________________________
[

] Senior Citizen
Age: ______________________

] OFW
[ ] Land-based
[ ] Sea-based

Age: __ Gender: M__ F__ Civil Status: _________

Contact Number: __________________________
Spouse: ___________________________________
Address: __________________________________
Contact Number: ___________________________
Place of Detention: _________________________
[

] Oppositors/Others

NAME
ADDRESS:
____________________________
_______________________________________________________
____________________________
_______________________________________________________
Facts of the Case: ________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Cause of Action/Nature of the Offense: ______________________________________________________
________________________________________________________________________________________
Pending in Court?
YES [ ] NO [ ]
Court/Body/Tribunal ___________________
Title of the Case: ________________________________________________________________________
Proof of Indigency Submitted (if any):
1. Income Tax Return
[ ]
3. Barangay Certificate of Indigency [ ]
2. DSWD Certification
[ ]
4. Others: Payslips, etc.
[ ]

VII Action Taken By Lawyer: ___________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________