Sample of Affidavit of Complaint

Republic of the Philippines )

____________, ________ ) s.s.
x- - - - - - - - - - - - - - - - - - - - - -x

AFFIDAVIT OF COMPLAINT

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.
_________________________
Judge
WITNESSES:

__________________________

__________________________
PETITION

______ 20__ (Date)

 _________ Addressee’s Name

_________ Addressee’s Title

________________ (Addressee’s Address)

 _____________Ref / Sub

Dear ________ / To whom it may concern

I am writing to appeal my academic dismissal from ________. I was supposed to

appear for ___________examination on ___________ and ____________ on
_________, 2012 for the_______ semester. However, I could not appear for the
examinations as I was suffering from ___________ during this period. I was
hospitalised for _______ at the ____________. I was in no condition to appear for the
examinations. I intimated the university about this through a written document.

As per college laws I am entitled to appear for these two papers whenever I have been
certified Healthy by the medical examiner. I sent the application for appearing in these
exams along with medical certificate of fitness. However, I got no intimations in this
regard. When I contacted the examination department about this they said I didn’t need
to appear as I have been dismissed from the institute. I was shocked and felt confused
and mental anguish as it is not my fault.

Please take appropriate action and inform me. I have followed the rules and regulations
towards this end and I deserve the right to appear for the remaining two examinations.

I have enclosed copies of Intimation of Absence, University Examination Schedule,

Medical Prescriptions, Treatment Record and Medical Certificate for your reference.

Thank you.

Sincerely,
__________ Your Signature

__________Your

AGREED UPON BY THE FOLLOWING PEOPLE:

NAME ADDRESS/SCHOOL/TELEPHONE

1. _______________________________________________

2. _______________________________________________

3. _______________________________________________

4. _______________________________________________

5. _______________________________________________

6. _______________________________________________

7. _______________________________________________

8. _______________________________________________