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 the herein offended party and I am satisfied
that they voluntarily executed and understood their given affidavit.

_______________________
Prosecutor

WITNESSES