Republic of the Philippines

____________ Judicial Region

REGIONAL TRIAL COURT OF __________
____________________ CITY
Branch ___
_____________________ City

PEOPLE OF THE PHILIPPINES,

Plaintiff, Crim. Case No. _________

- versus - for

JUAN DELA CRUZ, ____________________

Accused.
X------------------------------------------------X

APPLICATION FOR PROBATION

The undersigned accused, JUAN DELA CRUZ, files this application 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 (Ᵽ1,000.00) 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 (Ᵽ1000.00); and

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

_____________ City, ______________.

JUAN DELA CRUZ

Print Name and Signature of Applicant