Revised DOJ-BOC Form No.

BOARD OF CLAIMS
(R. A. No. 7309)

Department of Justice
Manila

Picture

APPLICATION
1.

Name of Applicant

__________________________________________

2.

Address (Residence) :
Telephone
:

__________________________________________
__________________________________________

3.

Business Address
Telephone
:

__________________________________________
__________________________________________

4.

Date & Place of Birth :

__________________________________________

5.

Civil Status

6.

Name of Spouse

7.

Name of Child / Children:

:__________________ Nationality : ________________________

:

__________________________________________

Name
Date & Place of Birth
Age
a.______________________________________________________________________
b.______________________________________________________________________
c.______________________________________________________________________
d.______________________________________________________________________
e.______________________________________________________________________
8.

Nature of Claim:

(Check appropriate box and attach documents indicated)

a.

Unjustly accused, convicted and imprisoned but subsequently released by

virtue o judgment of acquittal.

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Certified True Copy of lowers courts decision of conviction;

Certified True Copy of appellate courts decision of acquittal; and
Certified True Copy of commitment order and released from
confinement by the jail warden or prison authority concerned.

b.

Unjustly detained and released without being charged.

( )

Any proof to show that he was unjustly detained without being charged.
(e. g. such as records of arrest; detention and release.)

c.

A victim of arbitrary or illegal detention by the authorities and defined in

the Revised Penal Code under final judgment of the court.

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d.

Victims of Violent Crime:

( )

Certified True Copy of Police Report

(Spot and Casualty Report in case of KIA);
Certified True Copy of Autopsy Report in case of Death;
Certified True Copy of Doctors Medical Certificate
(for Serious Physical Injuries/Rape);
Certified True Copy of Psychiatrist Certificate; if applicable; and
Certified True Copy of Death Certificate and
Medical Receipts, etc. (in case of Serious Physical Injuries)
Certified True Copy of Resolution / Information (in case of Rape)
For KIA, Certificate of Legal Beneficiaries / Declaration of Legal
Beneficiaries (Authenticated Copy)
For WIA, Certificate (wounded) with journal (Authenticated Copy)

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9.

If claimant is an heir, he/she shall submit the following :

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Certified True Copy of Marriage Certificate if claimant is the spouse;

Certified True Copy of Birth Certificate if claimant is a child/parent; or
Proof of relationship that the claimant is the mother/sister/grandparent.
Baranggay Certificate

Brief narration of incident giving cause of claim :

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
________
10.

History of Claim :
a. I.S. Crim. Case No. :_________________________________________
b. Compainant
:_________________________________________
c. Respondent/Accused:________________________________________
d. Nature of Offense :_________________________________________
Right thumb
mark
________________________
APPLICANT
(Signature over printed name)

SUBSCRIBED AND SWORN to before me this _____ day of_______________

2008, in the City of Manila, Philippines.

ADMINISTERING OFFICER

kayebongjanuary2008