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REPUBLIC OF THE PHILIPPINES) TACLOBAN CITY….……………../)S.S.

JUDICIAL AFFIDAVIT - COMPLAINANT I, _____________, ____ years old, Filipino and a residence of _______________ and a ___________ (occupation), after having been duly sworn to in accordance with law, hereby depose: That it was Police Investigator______________, who conducted the examination of the undersigned affiant in Police Station 2, Abucay, Tacloban City; That I hereby state, that in answering the questions asked of me as appearing below, I was fully conscious that I did so under oath and that I may face criminal liability for false testimony or perjury; Question 1: Are you complainant in this case? Answer: Yes, I am. the private

95-A. Question 4: What were you doing at the time of the incident? Answer: I was then inside our house. Caibaan. specifically at the dining table.Question 2: Why did you file this case against the accused _________? Answer: Because she uttered defamatory words against me in the presence of other persons. Question 5: What happened while you were drinking coffee? . Question 3: When and where did it happen? Answer: It happened on August 2. 2012 at around 7:00 o’clock in the morning. Tacloban City. drinking coffee. just outside of our residence in Brgy.

namagtrabaho ha abroad it im mga anak pagpinuta. after you asked her? Answer: She pointed her finger at me and uttered in a loud voice “Uy Elenita. I asked her “Ano it imo problema.Answer: I heard a female voice coming from the direction of our front yard. iyo na liwat ginsarang didi hit akon bungsaran!” Question 6: What did you do when you heard those words? Answer: I went out to verify and when I saw ___________ (suspect).” . if any. mga puta it im mga anak. nakabalay agi hit pagpinaputa ngan pagpinaputik hin iba-iba nga mga lalaki. aga-aga pa dako na iton imo boses?” Question 7: What did the suspect do. ayaw pagmalinis! Bugaw ka man ngani hit im mga anak. said in a loud manner “Hoy Elenita. it iyo basura.

Question 9: You mentioned that the utterance was made in the presence of other persons. Who were those persons? Answer: Rinalyn Reyes (witness) was there buying at the sari-sari store just in front of my house. .Question 8: What did you do if any after hearing the said utterance? Answer: I was shocked and I only told her “Hinay hinay ikaw hit imo mga yakan!” and then I went inside the house teary-eyed. after you went inside your house? Answer: Rinalyn Reyes came in after buying from the sari-sari store and comforted me since I was then crying. the owner of the said sari-sari store. was inside her store at that time. attending to Rinalyn. Mrs. Question 10: What happened if any. Dela Cruz.

I was issued a Certificate to File Action. Conciliation meetings were scheduled but Mrs. Question 12: As a result of the utterances hurled at you by ______ (accused). Thereafter. ___ (suspect) did not show up. ______ (suspect). the original of which is hereto attached as Exhibit ____. how much in moral damages would you like to ask? .Question 11: After the incident. I went to the Barangay Hall and filed a complaint against Mrs. what did you do if any? Answer: After I regained my composure. what if any did you feel? Answer: I felt embarrassed and humiliated…… Question 13: Because of the embarrassment and humiliation that you feel.

. ________________ Affiant SUBSCRIBED AND SWORN TO before me in the City of Tacloban. IN WITNESS WHEREOF. I have hereunto affixed my signature on this __ th day of _____________. in Tacloban City. Philippines this __th day of ______________. Question 14: Do you know of any reason why the accused would utter those defamatory remarks against you? Answer: Its probably because there is an existing misunderstanding between our families that started from a land dispute. Question 15: Do you have anything more to add to your statements? Answer: I have none for the moment. Philippines.Answer: I am asking for an award of __________ for moral damages.

IN WITNESS WHEREOF. in Tacloban City. ______________________ Investigator . I hereunto affixed my signature this ____ day of _________________ . the narrations thereof being completely his/her own.________________ ATTESTATION CLAUSE I certify that I conducted and supervised the examination and have faithfully recorded the questions and the corresponding answers of the witness _____________ and that he/she was never instructed or coached on the answers he/she is supposed to give.