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DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT
CITIZEN'S CHARTER SERVICE REQUEST FORM
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SERVICE TITLE: ISSUANCE OF CERTIFICATE OF INCUMBENCY OF LOCAL OFFICIALS
REFERENCE NO.
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DATE OF REQUEST
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NAME OF CLIENT/ORGANIZATION:
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Documentary RequirementsKindly Check the documents Needed
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CONTACT DETAILS:
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1. Letter Request
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2. Photocopy of valid ID of the OfficialOTHER NEEDED INFORMATION, if any:
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Name of Local OfficialPosition
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3. Certification of Services Rendered issued by the Barangay (For Barangay Officials only)
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Address:
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Term of Office:
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4. In case of discrepancy in the name, client must secure any of the following:
a.) Oath of Office
b.) Joint Affidavit of Two (2) Disinterested Persons
c.) Photocopy of Birth Certificate/Marriage Certificate		SIGNATURE:
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RECEIVED BY:DATE AND TIME RECEIVED
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ENDORSED TO RESPONSIBLE OFFICER:DATE AND TIME ENDORSED
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Name/Unit and Designation
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REMARKS:
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ACKNOWLEDGEMENT RECEIPT
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This is to acknowledge the service/s you have requested:
REFERENCE NO.
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SERVICE TITLE:Date ReceivedExpected Date of ReleaseDate of Release in case of extension



Republic of the Philippines
DEPARMENT OF THE INTERIOR AND LOCAL GOVERNMENT

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NAME OF RESPONSIBLE OFFICER/UNIT/DESIGNATION:CONTACT DETAILS:
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OFFICE ADDRESS: ______________________________________________________________________________________________________________________________________________________________________________________________________
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REMARKS:
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