REPUBLIC OF THE PHILIPPINES

OFFICE OF THE CITY PROSECUTOR

[CITY/MUNICIPALITY]

[Name],
Complainant,
I.S. No. _______

- versus - For: B.P. Blg. 22.

[Name],
Respondent.

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

COMPLAINT-AFFIDAVIT

The undersigned Complainant, by counsel, respectfully alleges under oath

that:

1. The Complainant is ___ [Name] ___, of legal age, married, Filipino and,
for purposes of this criminal complaint, with postal address at___ [Address]
___:

2. The Respondent is ___ [Name] ___, of legal age, married, __

[Nationality]___, and with the known address at ___ [Address] ___ where
summons and notices may be served:

3. This is a complaint against Respondent for violation of Batas Pambansa

Bilang 22 (Bouncing Checks Law) involving __ [number] __ of checks
amounting to [a total of] ____ [amount in words] __ (Php_____________), more
particularly described as follows:

[Issuing Bank] [Check No.] [Date Issued] [Amount]

For the record, and to form part of the herein complaint-affidavit, by

incorporation and reference, attached hereto as __ [Annex __] ___ is a/are
photocopy/ies of the above-mentioned check(s).

4. [State the circumstances surrounding the issuance by the Respondent

of the check/s]
5. The Complainant deposited the said check(s) on ____ [Date] _____ or
within ninety (90) days from the date appearing on the said check{s).

For the record, and to form part of the herein complaint-affidavit, by

incorporation and reference, attached hereto as __ [Annex __] ___ is a copy of
the deposit slip.

6. Complaint, upon being informed by the drawee bank ___ [Bank name]
_____that the deposited checks will not be honored on the ground of ___
[insufficiency of funds on the checking account or account closed] ____,
immediately sent a written demand letter1 dated ___ [Date] ___ to
Respondent informing the latter of the fact of dishonor of the above-
mentioned check(s).

For the record, and to form part of the herein complaint-affidavit, by

incorporation and reference, attached hereto as __ [Annex __] ___ is a copy of
the demand letter sent.

7. The said letter of demand and notice of dishonor which Complainant sent
by ___ [hand/post/registered mail] ______ to Respondent was received by the
latter ____ [personally or through a representative] ________ on __ [Date]
____. 2

8. Respondent has failed and/or refused and continues to fail and/or refuse
to make payments or to make arrangements for payment on the dishonored
check/s within five [5] banking days from the receipt of such notice of
dishonor, in accordance with Section 2 of B.P. Blg. 22. 3

8. Wherefore, premises considered, Complainant respectfully prays that after

notice and hearing, the Respondent be indicted for violation of B.P. BLG. 22
and for the complainant to recover his/her claim of ____ [amount in words]
1
The notice of dishonor required by Batas Pambansa Blg. 22 to be given to the drawer, maker
or issuer of a check should be written. [Amada Resterio v. People, G.R. No. 177438, September
24, 2012]

2
[I]t is not enough for the prosecution to prove that a notice of dishonor was sent to the
petitioner. It is also incumbent upon the prosecution to show "that the drawer of the check
received the said notice because the fact of service provided for in the law is reckoned from
receipt of such notice of dishonor by the [issuer] of the check. [Jaime Alferez v. People, G.R.
No. 182301, January 31, 2011]

If the service of the written notice of dishonor on the maker, drawer or issuer of the
dishonored check is by registered mail, the proof of service consists not only in the
presentation as evidence of the registry return receipt but also of the registry receipt together
with the authenticating affidavit of the person mailing the notice of dishonor. Without the
authenticating affidavit, the proof of giving the notice of dishonor is insufficient unless the
mailer personally testifies in court on the sending by registered mail. [Amada Resterio v.
People, G.R. No. 177438, September 24, 2012]

3
The making, drawing and issuance of a check payment of which is refused by the drawee
because of insufficient funds in or credit with such bank, when presented within ninety (90)
days from the date of the check, shall be prima facie evidence of knowledge of such
insufficiency of funds or credit unless such maker or drawer pays the holder thereof the
amount due thereon, or makes arrangements for payment in full by the drawee of such check
within (5) banking days after receiving notice that such check has not been paid by the
drawee. [Section 2, B.P. Blg. 22]
_____ Pesos (Php ______________), plus moral damages in the amount of ____
[Amount] ____, attorney’s fees in the amount of ___ [Amount] ___, and costs
of suit.

TO THE TRUTH OF THE FOREGOING, I have signed this Complaint-

Affidavit on [Date] at [Place].

[SIGNATURE]
[NAME]
Complainant-Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this _________ day of

[Month] ______ [Year] ___ with Complainant-Affiant exhibiting to me his/her
government issued identification consisting of [ID Type and No.] issued on
[Date] and expiring on [Date].
.

[SIGNATURE]
Investigating Prosecutor

CERTIFICATION

I HEREBY CERTIFY THAT I HAVE PERSONALLY EXAMINED THE

AFFIANT AND AM SATISFIED THAT HE/SHE VOLUNTARILY EXECUTED
AND UNDERSTOOD HIS/HER AFFIDAVIT.

[SIGNATURE]
Investigating Prosecutor