Republic of the Philippines

HUMAN RIGHTS VICTIMS CLAIMS BOARD

NOT FOR SALE

E. Virata Hall, E. Jacinto St., U.P. Diliman Campus

Diliman, Quezon City 1101

DOCKET No.
Time and Date Filed.

APPLICATION FOR REPARATION AND/OR RECOGNITION

(Please write legibly in black ink)

WARNING: Direct or indirect commission of fraud, collusion, falsification, misrepresentation of facts, or

any other kind of anomaly in the accomplishment of this form, or in obtaining any benefit under this
application shall be subject to CRIMINAL ACTION, punishable by 8-10 years imprisonment and other
accessory penalties as provided for under Republic Act No. 10368, Sec. 25.
Application for

REPARATION RECOGNITION

(From May 12, 2014 to Nov. 10, 2014, applicant must file personally at HRVCB Main Office or designated on-site satellite office.)

A. HUMAN RIGHTS VIOLATIONS VICTIM (HRVV)

Name of HRVV (Please write each letter on the box below, put spaces between last, first and middle name)

[Last Name] [space] [First Name] [space] [Middle Name] [space] [Name Extension, e.g. Jr, Sr, II, etc.]
Date of Birth

Place of Birth

Gender
Male
Female

Month

Day

Year

Date of Death (If Victim is Deceased)

Month

Day

Place of Death

Civil Status
Single
Married
Widow
Separated

Year

(This portion is to be filled up by the legal heir or authorized representative of HRVV, if HRVV is deceased, missing or
physically or mentally incapacitated)
Name of Applicant (Please write each letter on the box below, put spaces between last, first and middle name)

[Last Name] [space] [First Name] [space] [Middle Name] [space] [Name Extension, e.g. Jr, Sr, II, etc.]
Relationship to Victim: ___________________________
Date of Birth
Place of Birth

Gender
Male
Female

Month

Day

Year

Civil Status
Single
Married
Widow
Separated

B. APPLICANTS CONTACT DETAILS

Present Address

Contact Number

House/Building/Street Number + Street Name

Barangay/District

City/Municipality

Province

Permanent Mailing Address (If different from Present Address)

House/Building/Street Number + Street Name

Barangay/District

E-Mail Address

City/Municipality

Province

C. THIS PORTION IS FOR VERIFICATION PURPOSES ONLY

Immediate
Relatives of
Victim
Spouse
Oldest Living
Child
Father
Mother
Oldest Living
Sibling

Name

Birthday

Address

Contact Details
(Tel./CP/Email)

D. HUMAN RIGHTS VIOLATIONS (Please check applicable box)

(1) Killed
(2) Disappeared and still missing
(3) Tortured
(4) Raped or sexually abused
(5) Illegally detained
(6) Involuntarily exiled

(7) Unjust or illegal takeover of business;

confiscation of property; detention of
owner/s and/or their families; deprivation of livelihood
(8) Victims child kidnapped or exploited;
(9) Sexually offended during detention and/or
in the course of military and/or police operations
(10) Other violations and/or abuses similar or analogous
to 8 and 9, please specify:

____________________________________
________________________________________
Place/s and approximate date/s of incident/s

Alleged perpetrator (Name of Person/Unit/Group/Association)(if known)

ATTACHED DOCUMENTS:

(Please check applicable box)

Proof of human rights violations

Sworn statement* narrating circumstances of Human Rights Violation/s (HRV).
Sworn statement* of two (2) co-detainees or two (2) persons who have personal knowledge of the
circumstances surrounding the HRV
Warrant of arrest, seizure orders (PDA, PCO, ASSO), mission order and other similar documents
Certification by custodial government agencies on fact of detention, carpeta, police blotter, NBI files, and
other similar documents
Release papers
Declassified documents from the Department of National Defense
Court records
Original or duly certified lawyers records
Photographs with affidavit of proper authentication
Secondary sources of information from reliable sources such as church/NGO report, books documenting
HRVs, news clippings or other similar documents
Other documents:________________________________
Proof of identity of HRVV, legal heir/s or authorized representative
NSO-issued or Local Birth Certificate/s
NSO-issued or Local Marriage Certificate
NSO-issued or Local Death Certificate
Affidavit* of two (2) disinterested persons
Notarized authorization showing proof of identity of the authorized representative (In case HRVV is
physically incapacitated to file personally)
Government issued identification card
*Must be compliant with 2004 Rules of Notarial Practice. PAO and IBP offer free notarization.

I hereby swear and affirm that the information/s provided herein is/are true and correct of my own
personal knowledge and the document/s submitted is/are authentic. I further swear that I am fully aware
that I may incur criminal liability under the Revised Penal Code for any false information.

Applicants/Legal Heirs/Authorized Representatives

Signature Above Printed Name

Date

I likewise grant to the Board/Memorial Commission my prior informed consent to share/publish

information about my story for legal purposes other than the publication of the list of eligible claimants
and inclusion of the victims name in the Roll. (See Implementing Rules and Regulations of RA 10368,
Sec. 21 for confidentiality in certain instances.)

Applicants/Legal Heirs/Authorized Representatives

Signature Above Printed Name

Date