Republic of the Philippines

DEPARTMENT OF JUSTICE
CITY PROSECUTION OFFICE
Old City Hall Building
Tuguegarao City, Cagayan

___________________________,
Complainant, CASE No. _______

-versus-
For: ESTAFA AND VIOLATION
___________________________ OF BP 22
_,
Respondent.
x-------------------x

COMPLAINT-AFFIDAVIT

I, __________________, of legal age, Filipino citizen and a resident

of ______________, after having been duly sworn in accordance with law,
hereby depose and state that:

ULTIMATE FACTS

1. I am the sole proprietor of _____________________--;

2. It was sometime in 2013, when I have known the herein respondent

when she entered into a transaction with us as she has thereby
undertaken to_____________________________;

3. First days of our transaction went smoothly. The transactions were

actually consummated and transpired normally. There may be times
that she defaulted in the fate of the checks she had issued me for the
supposed payment of the procured and purchased items, the
respondent has made her ways to make good of the same;

4. The nature of our transactions has always been a one-time

transaction;

5. In the usual course of our transactions, respondent would always

issue ten (10) post-dated running checks representing the payment of
the items or products I parted to her;

6. This complaint charge arose from the last transaction I had with her
particularly the transaction we had last __________________ after
having had the five (5) post-dated issued checks got dishonoured by
the drawee bank;

7. The checks involved are particularly described as follows, to wit:

 1. ----------------------------------------

8. When the respective checks fell on their dates due, I presented the
March, May, June, and July checks to
_________________________. Unfortunately, the said drawee bank
dishonored the same. It appeared that the checks were “DRAWN
AGAINST INSUFFICIENT FUNDS (DAIF)” and that the respondent’s
account was closed (“ACCOUNT CLOSED”); Attached hereto are
the copies of the Checks with the respective stamps on their
faces as to they were DAIF or on the ground of ACCOUNT
CLOSED marked as Annex “A” to “A-1”, “B” to “B-1”, “C” to “C-
1”, “D” to “D-1” and “E” to “E-1”, respectively;

9. I informed the herein respondent regarding the fate of the checks she
issued me but she never paid attention to it as the same fall in deaf
ears;

10. I sent the respondent a demand letter dated

____________________ which I likewise personally handed to her.
In the same demand letter, she affixed her signature which the same
serves as a proof of her actual receipt of the demand letter I
personally wrote her; Attached hereto is the copy of the Demand
Letter and marked as Annex “F” and her signature whom she
affixed in the very same letter is marked as Annex “F-1”.

11. Unfortunately, up to this date, the respondent has never make good
of the checks she issued me and remained in passive in settling the
same;

12. The respondent by means of false pretense and fraudulent act that
her check is fully funded, draw, make and issue in my favor in
exchange for the medical supplies and items knowing fully well that
they have no funds in the drawee bank. And when the said checks
were presented, the same were dishonored by reason of “DRAWN
AGAINST INSUFFICIENT FUND (DAIF)” and “ACCOUNT CLOSED”;

13. Where it not for the said checks and for the assurance and
representation from her that the said checks were good checks and
would be covered by sufficient funds when presented for payment, I
would have not parted my products;

14. Despite demand, respondent failed to pay the value thereof to my

damage and prejudice in the aforementioned total amount
of ________________________________ Philippine Currency;

15. Thus, with the foregoing, I am formally charging

_____________________ for ESTAFA prescribed and penalized
 under Revised Penal Code of the Philippines and for VIOLATION OF
BATAS PAMBASA BILANG 22;

TO THE TRUTH OF THE FOREGOING, I have hereunto set our

hands, this _____ day of _______________, at Tuguegarao City, Cagayan.

___________________________________________
Affiant

SUBSCRIBED AND SWORN to before me, this _____ day of

_______________, at Tuguegarao City, Cagayan. Affiant exhibiting his
_____________________ as proof of his identity.

Doc. No. : ________

Page No. : ________
Book No. : ________
Series of 2015.

CERTIFICATION

I hereby certify that I have personally examined the affiant-

complainant and that I am satisfied that he voluntarily executed and
understood the contents of the above complaint-affidavit.

_______________________________