REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF JUSTICE
OFFICE OF THE (_)CITY (_) MUNICIPAL (_) PROVINCIAL PROSECUTOR
(_)CITY (_) MUNICIPALITY (_) PROVINCE OF ____________

____________________
Complainant,

- Versus - DOCKET NO. _____________

FOR: Grave Coercion

__________________
__________________
Respondent/s,
X---------------------------------x

COMPLAINT-AFFIDAVIT

I, ______________________, of legal age, (single/married) Filipino, and with address at

________________________________________________________________after having been
sworn in accordance with law, hereby depose and state:

1. I am an employee of ________________, a (_) private company, (_)government office,

whose office is located in __________________________.

2. That sometime in ______________, I was asked by ____________________, my

superior in the said office, to be vaccinated and threatened that if I will not be
vaccinated, I will (_) not be allowed to report for work, (_) removed from office, (_)
demoted, (_) my reporting days for work will be reduced
(_)__________________________________.

3. That I issued a letter of refusal to my employer, Attached here as Annex “ A” justifying

my refusal as an exercise of my constitutional right to life under Art.II Sec. 11 and Art. III
Sec. 1. because I fear that the vaccination will cause serious and irreversible harm to me
once administered, and also because there are a lot of reports of immediate casualties
of the vaccines online and with people I know of, and I do not want to risk my life into
taking this vaccination. Also, it is below human dignity to be experimented on, or be a
guinea pig for a vaccine which we cannot determine yet of the long-term adverse
effects. Furthermore, this threat to my work will deny me the capacity to support myself
and my family, especially in this pandemic where death will not be because of the virus
but because of hunger.

4. In addition to this, even after I have informed them of this decision and that the same is
supported by DOLE Advisory No. 3 Series of 2021, the (_) violence, (_)threat, (_)
intimidation (_) ____________________ continues.

5. That right now, my status in the said office is that (_) I have been discriminated against,
(_) not allowed to report for work (_) my salary has been reduced, (_) I was dismissed
from work, (_) _______________________________.

6. That I am therefore executing this Complaint-Affidavit in support of the charges for

Grave Coercion under Art. 286 of the Revised Penal Code against the said respondent,
__________________, who may be served with subpoena and other processes of this
 Honorable Office at (his/her) last known address at
______________________________________________________, Philippines.

IN WITNESS WHEREOF, I have hereunto set my hands this ____ day of _____________, 20__ at
______________, Philippines.

__________________
Complainant

SUBSCRIBED AND SWORN to before me this ____ day of _____________, 20__ at

__________________________________. I hereby certify that I have examined the Affiant and
that I am fully satisfied that (he/she) has voluntarily executed and understood the contents of
(his/her) Complaint-Affidavit.

__________________
Administering Officer