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1. LSD Form No. 1, s. 2005
CSC-RO4
REQUEST FOR CERTIFICATE OF NO PENDING CASE
Name:_______________________________________________________________________ Surname
First Name Middle Name
Sex: ___________ Civil Status: ____________ Maiden Name: ______________________
Date of Birth: ______________________ Place of Birth: ___________________________
Present Office: ______________________________________________________________
Present Position: ____________________________________________________________
Purpose of Request : ________________________________________________________
________________________________________________________
Requested by:
____________________________________
(Printed Name and Signature)
(IMPORTANT: See Back Portion for the Requirements)
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REQUIREMENTS:
O.R. No.: _______________
Date : _______________
Cashier : _______________
Time Received: ________________
Time Released: ________________

2. 1. Present Original and attached photocopy of at least one (1) valid I.D. card with name,
picture and signature of the applicant, and name and signature of the issuing officer (i.e.
Driver’s/ PRC License, BIR, GSIS/SSS, Postal, Voter’s ID, Office/School, valid Passport)
2. Payment of ₱100.00 (to be paid at the Cashier), EXCEPT FOR RETIREMENT
PURPOSES.
3. In case of Death Claims, photocopy of Death Certificate is needed.
4. If filing of Request is filed through a representative:
a. Authorization letter executed by the applicant;
b. Original and photocopy of at least one (1) valid I.D. card of the
person requesting and
c. Original and photocopy of at lest one (1) valid I.D. card of the
representative