REPUIBLIC OF THE PHILIPPINES )

  ) s.s.  

COMPLAINT-AFFIDAVIT

I, ________________, ______ citizen , of legal age, married, and a resident of ________________, after
being sworn to in accordance with law, depose and state:

1. That with the assistance of my legal counsel in preparing this Complaint-Affidavit, I

am filing a complaint against ________ for violation of Batas Pambansa Blg. (BP) 22, who
can be served with summons and notices at ______________;

2. That sometime in ________, _________ issued in my favor _____ checks in the total amount of
______ as supposed payment for the loan which I have extended to him, to wit:

Date of Check Check No. Amount (in Reason of Dishonor

Php)
20 January 2015 BDO 0000143185 45,000.00 Account Closed
28 February 2015 BDO 0000143186 45,000.00 Account Closed
31 March 2015 TRB3687513 20,000.00 Account Closed
10 April 2015 TRB3687514 25,000.00 Account Closed
2 May 2015 TRB3352238 450,000.00 Account Closed
21 May 2015 BDO0000143215 168,000.00 Account Closed
Total 753,000.00

3. That at the time __________ issued the delivered the said check to me, he made the assurance
and representation that the said check is a good check and would be covered by sufficient funds
when presented for payment;

4. That when the above-mentioned checks was deposited, the same were dishonored and returned by
the bank on the ground that the same was drawn against a " ACCOUNT CLOSED ". A copy of
the said checks is hereto attached as Annexes “A" to “A-5”;

5. That I immediately notified _________ of the dishonor and return of the said checks and
demanded from him that he make good the said checks within ten (10) days from receipt thereof.
A copy of the Demand Letter dated 24 July 2015, duly received and signed ___________, is
attached hereto as Annex “B”;

6. That when _________ unjustifiably ignored my demand, I asked the assistance of my legal
counsel who immediately sent a formal demand letter through LBC Express. A copy of the said
Demand Letter dated 14 September 2015 and LBC Receipt No. SAL0210000041543 is attached
hereto as Annexes "C" and “C-1”, respectively;
 7. That _________ received the Demand Letter dated 14 September 2015 as he was able to make
cash deposits to my bank account. A copy of the said deposit slip, received thru e-mail from
Edwin S. Uson, is attached hereto as Annex “D”;

8. That when __________suddenly stopped to make good of the checks, a formal demand letter was
sent by my counsel and the same was personally received by him. A copy of the said Demand
Letter dated 7 January 2016, duly signed and received by Edwin S. Uson, is attached hereto as
Annex “E”;

9. As of date however, __________ failed and refused, and continue to fail and refuse to redeem in
cash the face amount of the unfunded returned check. Filing of this case was even suspended
for almost several times already just to give them the ample time and opportunity to settle
their obligations in full, but the same served futile; and

10. I am executing this affidavit to attest to the truth of the foregoing facts and for the purpose of
charging EDWIN S. USON for violation of the provisions of BATAS PAMBANSA BLG. 22
and ESTAFA.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this 19th day of May 2017 at ________.

__________________
Complainant

SUBSCRIBED AND SWORN to before me this _____________ at _____________ .I hereby

certify that I have examined the Affiant and that I am fully satisfied that she has voluntarily executed and
understood the contents of her Complaint-Affidavit.

_________________________
Administering Officer