FORM NO. 291.

Affidavit of Recognizance in Lieu of Bail

(Caption and Title)

The undersigned, being charged with violation of _________________ for a light

felony punishable by a penalty not higher than 6 months imprisonment and/or fine of not
more than P2,000 being unable to pose the required cash or bail-bond, hereby binds
himself, pending final decision of the above-entitled case, to appear before the Court
when so ordered.
The undersigned hereby further bind himself to accept the authority of ________
in whose custody he has been placed by the Court.
(Signature of the Accused)
(Signature and address of the Custodian)
Witnesses:
JURAT
RECORD OF APPEARANCE OF ACCUSED BEFORE THE CLERK OF COURT
Dates Signature and Thumbmark Clerks Signature
of Accused
______________________ ______________________ ______________________
______________________ ______________________ ______________________
______________________ ______________________ ______________________