COMPLAINT-AFFIDAVIT

I, _____________, Filipino, of legal age, (single / married / widow), and a resident

of _____________, Philippines, after being sworn to in accordance with law,
depose and state:

That I know the person of __Respondent__, who is a resident of _____________,

Philippines;

That sometime in the morning of __date of issue__, at __place of issue__,

Philippines, the said __Respondent__ issued in my favor a __Name of Bank__
Check No. _____________ in the amount of P_____________ as supposed
payment for the loan accommodation of P_____________, which I have extended
to (him/her);
That the said check is drawn against the account of the said __Respondent__ at
__Name of Bank__ with Account No. _____________;

That at the time the said __Respondent__ issued the delivered the said check to
me, (he/she) made the assurance and representation that the said check is a
good check and would be covered by sufficient funds when
presented for payment;

However, when the above-mentioned check was deposited, the same was
dishonored and returned by the bank on the ground that the same was drawn
against a "CLOSED ACCOUNT".A true and faithful machine reproduction of the
said check is hereto attached as Annex "____";

As such, I immediately notified said __Respondent__ of the dishonor and

return of the said check and demanded from (him/her) that (he/she) make
good the said check within _____________ (____) days from receipt thereof. A true
and faithful machine reproduction of my demand letter to (him/her) is hereto
attached as Annex "____"

When said __Respondent__ failed to heed my demands, I endorsed the said

check to my legal counsel who immediately sent a formal demand letter
through registered mail with return card on _____________, which was received
by the said __Respondent__ on _____________.As of date however, __Respondent__
has unjustifiably ignored all these demands to pay the said account and/or to
redeem the said returned check. A true and faithful machine reproduction of
my demand letter to (him/her) is hereto attached as Annex ____"
I am therefore executing this Complaint-Affidavit in support of the
charges for Violation of Batas Pambansa Bilang 22 against the said
__Respondent__, who may be served with subpoena and other processes of
this Honorable Office at (his/her) last known address at _____________,
Philippines;
IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at
_____________, Philippines.

COMPLAINANT
SUBSCRIBED AND SWORN to before me this _____________ at _____________.I
hereby certify that I have examined the Affiant and that I am fully satisfied
that (he/she) has voluntarily executed and understood the contents of
(his/her) Complaint-Affidavit.
Administering Officer