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:

_______________________________________

_______________________________________

_______________________________________