REPUBLIC OF THE PHILIPPINES

REGIONAL TRIAL COURT

BRANCH ________, PALAYAN CITY

PEOPLE OF THE PHILIPPINES

-versus- Criminal Case

No. ________________________
For: RAPE

MARIO _____________________,
Accused.
x---------------------------------------------x

COMPLAINT AFFIDAVIT

I, Marissa, 12 years old, single, Filipino, and a resident of 122 Atate, Palayan City, Nueva Ecija,
after having sworn in accordance with law, despise and state that:

1. The accused in this case is my cousin, Mario, a resident of 123 Atate, Palayan City, Nueva
Ecija;
2. On March 1, 2018, I woke up as I felt the accused’s hands on my legs. I was not scared at
first but when he started caressing my hips and breasts I started crying as the accused threatened
to hurt me if I resisted. He slid his hands inside my panty and inserted his middle finger in my vagina.
I cried ever more because what he did really hurt me. After a few moments he suddenly stopped
and quickly left our house;
3. I immediately told my mother what happened and we went to a hospital. According to the
doctor, I suffered fresh slight lacerations inside my vagina as evidenced by a medical certificate
hereto attached as Exhibit “A”;
4. I am executing this Complaint-Affidavit to attest the truth of the foregoing and in support of
the appropriate criminal charges against the accused for Rape under Article 266-A of the Revised
Penal Code, as amended.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my signature this
__________________________, in Talavera, Nueva Ecija.

MARISSA
Complainant

Under the guidance of

__________________
Mother of the complainant

SUBSCRIBED AND SWORN TO before me this ____________________, in Talavera, Nueva

Ecija, affiant exhibiting to me his competent evidence of identity.

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 ATTESTATION

I, ATTY. _________________________________________, with office address at

Palayan, Nueva Ecija, hereby attest under oath that:

I personally conducted the interrogation of Marissa 122 Atate, Palayan City, Nueva Ecija, the
complainant in the above-captioned case. I have faithfully recorded the questions I asked Ms. Marissa
and the corresponding answers she gave me and neither I nor any other person then present coached
Ms. Marissa regarding her answers.

ATTY. ___________________________
Affiant
IBP No.

SUBSCRIBED AND SWORN TO before me this _________________, in

___________________________.

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