Republic of the Philippines)

City of Las Pinas

)s.s.

COMPLAINT-AFFIDAVIT BP22
I, ,XYZ of legal age, widow, Filipino with residence address at
being duly sworn in accordance with law hereby depose and say, that:

after

1. On or about July 4, 2012, borrowed from me P80o,000.00; (copy of the

acknowledgment receipt is hereto attached as Annex B.
2. As payment for the money she borrowed, she drew and issued to me in my
residence in Manila two (2) post-dated checks, to wit:
Check No.

Date

Amount

Drawee Bank

the first check representing the capital and the second check the interest.
(xerox copies of the checks are hereto attached as Annexes c and d);
2. When, the above described checks were presented for encashment to
the drawee bank on their due dates, both checks were all dishonored by
reason of ACCOUNT insufficient;
3. Despite the notice given and received personally by, requiring her to
pay within 5 days from receipt, she still failed to pay me the total value of the
checks. ( xerox copy of the Notice is hereto attached as Annex e);
3. Ms can be served with subpoena at I am executing this Affidavit to
attest to the truth of the foregoing and for the purpose of submitting
the same to the Office of the City Prosecutor of Manila for the filing of
appropriate criminal charges for violation of Batas Pambasa Bilang
22.

AFFIANT FURTHER SAYETH NAUGHT.

Affiant
SUBSCRIBED AND SWORN TO before me this _________________ at
the City of las pinas, Philippines.

ADMINISTERING OFFICER
This is to certify that I have personally examined the affiant and I am
fully satisfied that she voluntarily executed and understood this affidavit.

ADMINISTERING OFFICER