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Republic of the Philippines

REGIONAL TRIAL COURT
7th Judicial Region
Cebu City

People of the Philippines, CRIMINAL CASE NO:

Plaintiff,

-versus- For

______________. QUALIFIED THEFT

Accused.

X- - - - - - - - - - - - - - - - - - - - - - - - - - X

JUDICIAL AFFIDAVIT
of __________

I, _________, of legal age, Filipino, married, a businessman, and a

resident of __________________, and after having been duly sworn to in
accordance with law, hereby deposes and states.

PREFATORY STATEMENT

That the taking of my Judicial Affidavit was administered and

supervised by ______________ and was done at his Law Office at
_______________, and I am fully aware and cognizant of the questions
asked of me by ____________ and my answers thereto are under oath being
aware that I may face criminal liability for false testimony or perjury. I
likewise requested that the questions asked of me be in English as well as
my answers thereto also in English which I speak and understand for clarity
and that the other information and/or requirements of Sec. 3, A.M. 12-8-8-
SC as explained to me by the administering lawyer are contained in my
Judicial Affidavit the rest which reads, to wit:

Q1: Please state your name and other personal circumstances?

A1: I am __________, married, a businessman, owner of a trading

store.

Q2: Mr. Witness, you said that you are an owner of a store, where is
it located?

A2: It is in _________, Sir.

Q3: What happen at around 2:30 in the afternoon on February 20,

2019?

A3: My cellphone and cash were stolen, Sir.

Q4: How did you know that it was stolen?

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A4: Because at around 1 o’clock in the afternoon, when I was about

to leave the store, the drawer of my desk was partially opened,
and when I opened it to check, my cellphone and the cash I left
inside were missing, Sir.

Q5: And did you know the persons who stole your belongings, Mr.
Witness?

A5: Yes, Sir.

Q6: How did you know them?

A6: Because they are my employees in the store, sir.

Q7: What evidence/s can you present to prove this fact?

A7: The video footage of the CCTV Camera installed in my store,

Sir.

Q8: Did you take a look at the CCTV Camera footage?

A8: Yes, Sir.

Q9: What did you do after seeing the footage of the CCTV camera?

A9: I immediately, went to the Carbon Police Station to report the

matter, as evidence in the Police Report.

Q10: Is there anything else you may add to your testimony?

A10: That is all for the meantime, Sir.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

th
6 day of March, 2019 at Cebu City, Philippines.

__________
Affiant

SUBSCRIBED AND SWORN to before me this 6 th day of March,

2019 at Cebu City, Philippines, after I have personally examined the affiant
and that I am convinced that he voluntarily executed this affidavit and
understood the contents thereof.

Notary Public/Administering Officer

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ATTESTATION

I, ________________, with Law Office at _____________, hereby

attest that I have conducted and supervised the examination of the above-
named affiant/witness at my office stated above, and further declared that:

1. I faithfully recorded or caused to be recorded the questions I asked

and the corresponding answers the affiant/witness gave; and

2. Neither I nor any other person then present or assisting me coached

the affiant/witness regarding the latter’s answers.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

____ day of _______ at _________, Philippines.

Notary Public

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Series of 2019.