N.B.

: This form shall serve only as a guide and may be in a language or dialect known to the
complainant-affiant.
Republic of the Philippines )

Republika ng Pilipinas)

_____________________ ) S.S.

_________________ ) S.S.

AFFIDAVIT

SINUMPAANG SALAYSAY

I, __________________, single/married,
____ years old, presently residing at
_________________________, under oath,
do hereby depose and state that:

Ako, si ___________________, walang

asawa/may asawa, ____ taong gulang,
kasalukuyang
naninirahan
sa
_______________________,
pagkatapos
makapanumpa ng naaayon sa batas, ay
malayang nagsasaysay na:

1. I have a savings/time/current account

deposit with _________________Bank,
_______________ Branch, with office
address at ________________________.
The said deposit is designated as Account
No. __________________ and has a
balance of ________________________
(Php
________________)
as
of
____________________, 20__.

1. Ako ay may savings/time/current account

deposit sa ____________________ Bank,
_________________
Branch
na
matatagpuan sa ______(ADDRESS)__.
Ang nasabing deposito ay may Account
No. _________________________ at may
balanseng
nagkakahalaga
ng
_______________________
(Php
________) noong ________________.

2. (State WHAT is the incident being

complained of, WHEN and WHERE it
happened.)

2. (Isalaysay kung ANO ang insidenteng

inirereklamo, KAILAN
at SAAN ito
naganap)

3. (Describe HOW the incident transpired.)

3. (Isalaysay kung PAANO naganap ang

insidente.)

4. (If known, state the name or identity of the

alleged perpetrator of the incident
complained of and that persons position in
the bank.)

4. (Kung kilala, isalaysay kung SINO ang may

kagagawan ng insidenteng inirerekklamo
at ano ang posisyon niya sa Bangko.)

5. (If likewise known, state WHY the incident

happened.)

5. (Kung alam din, isalaysay kung BAKIT

naganap ang insidente)

6. (If any, state the name or identity of the

witnesses to the incident or the persons
who may be able to attest thereto.)

6. (Kung mayroon, isalaysay kung sino-sino

ang nakakita sa insidente o kasama nang
maganap
ang
insidente
o
makapagpapatunay nito.)

7. (If any, state the documents that may

prove the incident and attach copies
thereof to the affidavit.)

7. (Kung mayroon, sabihin kung anu-anong

mga dokumento ang magpapatunay sa
mga nakasaad sa itaas at maglakip ng sipi
o kopya nito sa salaysay.)

8. I have not commenced any action or filed

any claim involving the same issues before
the BSP or any court, tribunal or quasijudicial agency and, to the best of my
knowledge, no such other action or claim
is pending therein. (If there is a similar
case or action, full disclosure of the status
of the same should be done. The following
details
should
be
provided:
the
court/tribunal/government agency where
the action/claim is filed; nature of
action/claim; parties; date action/claim was
filed; etc.)

8. Ako ay walang ibang isinampang reklamo

sa anumang hukuman o tanggapan laban
sa nabanggit na bankgo at mga tao hinggil
sa pangyayaring nakasaad sa itaas, at sa
aking pagkakaalam ay walang ibang
kasong katulad ng reklamong ito ang
nakasampa kung saan man. (Kung
mayroong
nakasampang
kasong
kahalintulad ng reklamong ito, dapat isaad
ang mga detalye nito tulad ng hukuman o
tanggapang
pinagsampahan,
kailan
isinampa, sino ang mga partido, ano ang
kasong isinampa, atbp.)

9. If I should thereafter learn that a similar

action or claim has been filed or is pending
before a court. tribunal or agency, I
undertake to report that fact within five (5)
days therefrom to PDIC.

9. Ipinangangako ko na kung malalaman ko

na
mayroong
kaso
o
reklamong
kahalintulad nito ang nakasampa sa
anumang hukuman o tanggapan ay
ipaaalam ko ito sa PDIC sa loob ng limang
(5) araw.

10. (Include only if the complaint involves a

deposit in the bank) By reason of the fact
that my deposit with Account No.
_____________ is involved in this
complaint, I am expressly authorizing
PDIC and/or any of its duly-authorized
representatives to examine all the records
of the said deposit account and secure
copies thereof in accordance with the
exception provided for under Republic Act
No. 1405 (Law on Secrecy of Bank
Deposits).

10. (Ilagay kung ang reklamo ay nakabatay sa

deposito sa bangko) Sa kadahilanang ang
reklamong ito ay nakabatay sa nabanggit
na deposito ko na may Account No.
___________ sa naturang bangko, aking
hayagang pinahihintulutan ang PDIC o
sinumang kinatawan nito na suriin ang
lahat ng rekord o talaan ng aking deposito
at makakuha o makapagpakopya ng
anumang dokumento o rekord/talaan
hinggil dito ayon sa liban o exception na
nakasaad sa Republic Act No. 1405 (Law
on Secrecy of Bank Deposits).

11.

I am executing this affidavit to attest to

the truth of the foregoing and for whatever
legal purpose it may serve.

11. Isinasagawa ko ang salaysay na ito upang

patotohanan ang lahat ng nakasaad sa
itaas at para sa anupamang kadahilanang
naaayon sa batas.

12. At the moment, affiant further sayeth

naught.

12. Sa ngayon, ay wala na akong nais pang

sabihin.

IN WITNESS WHEREOF, I have hereunto set

my hand this ____ day of __________, 20___,
in ________________, Philippines.

BILANG KATUNAYAN NG LAHAT, ako ay

lumalagda
ngayong
ika-___
ng
_____________,
20__,
sa
________________, Pilipinas.

_________________

_______________

Nagsasaysay

Affiant

SUBSCRIBED AND SWORN to before me

this ____ day of ____________, 20___, in
_____________, Philippines, with the affiant
exhibiting his/her Community Tax Cert. No.
______________,
issued
on
_______________, at ________________.

SINUMPAAN AT NILAGDAAN sa harap ko

ngayong ika-____ ng ________________,
20__, sa ____________________________,
at ipinakita sa akin ng nagsasaysay ang
kanyang
Community
Tax
Cert.
No.
_____________, na ipinagkaloob noong
____________________,
sa
_________________________.

Notaryo Publiko

Notary Public

Doc. No. ______

Page No. ______
Book No. ______
Series of 20___.

Doc. No. _______

Page No. _______
Book No. _______
Series of 20___.