Republic of the Philippines)

____________, ________ ) s.s.

x- - - - - - - - - - - - - - - - - - - - - -x

COMPLAINT AFFIDAVIT

The UNDERSIGNED, __________________________, accuses

_________, of _____________, committed as follows, to wit:

That on or about _________, at about _____________ in the

_________________, ______________, Philippines, the said accused did
then and there willfully, unlawfully, feloniously, and by means of
_____________, committed _____________, upon the undersigned directly
by overt acts to wit:

(state the details how the crime was committed).

The undersigned executed this affidavit to attest the truthfulness of the

foregoing facts and to support the filing of Criminal Cases against
_______________________________ for violations of
________________________.

___________, this _____ day of __________, ____.

____________________________
Offended Party

SUBSCRIBED AND SWORN to before me this ___ day of _______ at

_______________. I HEREBY CERTIFY that I have personally examined
PHILIPPINE LEGAL FORMS 2015 the herein offended party and I am
satisfied that they voluntarily executed and understood their given affidavit.

_______________________
Prosecutor

WITNESSES