REPUBLIC OF THE PHILIPPINES

OFFICE OF THE CITY PROSECUTOR

QUEZON CITY

________________,
Complainant,
I.S. No. __________________
For: Reckless Imprudence
Resulting in Damage to Property
-versus-

__________________,
Respondents.
x------------------------------------------x

COMPLAINT-AFFIDAVIT

I, __________________, of legal age, married, Filipino, and a resident of

________________________, under oath, respectfully state that:

1. I am the taxi operator and owner of a Toyota Vios Taxicab with an OR No.
________________, CR No. _____________, MV File No. _____________, Chassis No.
____________, and with Plate No. __________. A copy of Deed of Sale of Motor
Vehicle Including LTFRB Franchise is hereto attached as Annex “A” and a copy of
Deed of Sale of Motor Vehicle including Taxi Franchise is hereto attached as
Annex “B”;

2. That on or about 10:30 p.m. of July 3, 2017, along the Southbound Lane of EDSA
near Annapolis Street, Barangay Bagong Lipunan ng Crame, Quezon City,
respondent ____________, who is a resident of _________________, was driving a
DAEWOO BUS (Passenger Bus) with Plate No. ____________ which is registered
under the name of ___________________ with an address at ______________________, in
reckless, careless, negligent, and imprudent manner, without regard to traffic
laws, rules, and regulations, and without taking the necessary care and
precaution to avoid the accident, hit and bumped the rear right corner of the
above-mentioned Toyota Vios Taxicab driven by _____________________thereby
causing damage to my Toyota Vios Taxicab;

3. As consequence due to the strong impact, the Toyota Vios Taxicab was damaged
which would require repair and/or restoration. In support of the charge, I am
submitting proof as to damage on my Toyota Vios Taxicab and cost of its repair
and/or restoration estimated at Php 72,979.00 by Web Washer Auto Repair
Shop, a copy of which is hereto attached as Annex “C”;

4. The collision from the point of impact causing damages to back glass, trunklid
panel, Qtr Panel, Bumper, and among others of the rear right portion of my Taxi
Vios Taxicab. Photos of the actual damages to Toyota Vios Taxicab is hereto
attached as Annex “D”;

5. Investigation shows that shortly before the accident, the driver of the Toyota
Vios Taxicab was driving along the Southbound Lane of Edsa and upon reaching
the place of occurrence, was hit and bumped in the rear right corner from behind
 by the DAEWOO Passenger Bus driven by ____________________. As a result of the
collision, my Toyota Vios Taxicab incurred damages, a copy of PNP Incident
Report Form - Traffic Accident Investigation Report is hereto attached as Annex
“E”;

6. Also, as contained in the affidavit of ________________________, driver of Toyota Vios

Taxicab, he was then carefully driving the Toyota Vios Taxicab on the proper
lane which under normal conditions could be considered so safe and
manageable and he was about to turn right when suddenly the DAEWOO
Passenger Bus mentioned-above driven by the respondent suddenly hit and
bumped the rear right portion of the Toyota Vios Taxicab, a copy of Affidavit of
____________________, to prove the truth of the allegations herein is hereto attached
as Annex “F”;

7. Moreover, the respondent’s irresponsible and reckless act of driving of the

Passenger Bus appears to be the main cause of the collision;

8. Clearly, the respondent driver failed to exercise reasonable care and diligence.
Hence, the respondent driver ________________ and his Operator ___________________
should be made liable for the resulting damages to my Toyota Vios Taxicab;

9. I am executing this Complaint-Affidavit to attest to the truth of the foregoing and

in support of the charges for Reckless Imprudence Resulting in Damage to
Property against the Respondents.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __th day of

__________________ at Quezon City.

_______________________
Complainant

SUBSCRIBED AND SWORN to before me this ___ th day of _________ at Quezon City.

ASST. STATE PROSECUTOR

CERTIFICATION

This is to certify that I personally examined the affiant who affirmed to me that all
the above allegations are true and correct of his own knowledge and information.

ASST. STATE PROSECUTOR