REPUBLIC OF THE PHILIPPINES )

CITY OF ILIGAN ) s.s

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

COMPLAINT - AFFIDAVIT

I, ___________________, of legal age, Filipino, married, a resident

of _____________________, after having been duly sworn to in accordance
with law, do hereby depose and say that:

1. I am currently employed at ________________ as ____________

employee currently detailed at __________________________;

2. On _____________ at around 3:00 in the afternoon I was at my

office in ______________ performing my daily tasks;

3. On the same day, while I was performing my designated job, one of

my colleagues informed me that someone is looking
________________, one of my colleagues also, but she was not
around on the same day;

4. Consequently, I was the one who confronted the said individual,

that there and then, the said individual was identified as
__________________, herein respondent, who approached me
indignantly and uttered the words “Nganong ang gehatag ninyo
nga stall sa akua kay naa nay tag-iya? Kung ako maglagot
ninyo, pamusilon tamo sa night market kay kwartaan ang
among pamilya sa Lanao”;

5. After our confrontation, I immediately went to _______________

located in the same vicinity where I am currently employed and
there I made an Incident Report conducted by _______________
who was the investigating officer at that time. Attached herein is
the copy of the Incident Report exhibited as “ANNEX A”;

6. Due to the said willful, unlawful and felonious threat inflicted by the
respondent, I, suffered and continue to suffer serious anxiety,
mental anguish, sleepless nights, fear and trauma not to mention
the damage they caused to my reputation among my colleagues
and the general public who witnessed the incident;
 7. That I am executing this affidavit to attest the truth of the
foregoing statements.

IN WITNESS WHEREOF, I have hereunto set my hand this January

______________________ at ________________________.

__________________________
Complainant

SUBSCRIBED AND SWORN to before me this _______________ at

____________________ by the affiant whom I personally examined and I
am satisfied that he voluntary executed and understood her affidavit.

__________________________
Administering Officer