REPUBLIC OF THE PHILIPPINES)

CITY OF ROXAS )
x------------------------------------x

COMPLAINT AFFIDAVIT

I, _________________ of legal age, married and a ___________________, after

been duly sworn to in accordance with law, do hereby depose and state that;

1. I am complaining against ____________ for the following:

A. I and ___________ entered into a loan agreement as follows:

July 20, 2022, she borrowed P60,000.00;

August 15, 2022, she again borrowed P2,000;
August 31, 2022, she additionally borrowed P1,500;
September 19, 2022, another P1,500 was barrowed by Jeanny M. Apaso;
and;
October 27, 2022, she again borrowed P2,000;

Attached as Annex “A” to “ A-4” are the Loan Agreement and Palawan
Receipt of addinational loan that __________ received the
aforementioned amount from ______________.

B. _____________, told me that she will leave her Development Bank of the
Philippines ATM card with account number ______________to me and
withdraw her payment every 15th day and 30th day of the month;

Attached as Annex “B” is the Development Bank of the Philippines ATM

card with account number _____________ to prove that
____________give her ATM card to _______________ to satisfy her loan
obligation.

C. She told me that she is working from _________ as a Job Order. So,
being employed from __________l, I allowed her to borrow such amount
on the basis that she will pay me since she has a reputation to hold a
public employment;

D. On November 15, 2022, when I was about to withdraw her payment from
her ATM as what she said, her ATM has no balance, hence, I tried to
contact her but unfortunately, I was unable to reach her;

E. On November 30, 2022, the same thing happened, her ATM card has no
balance. Hence, I tried my best to contact her and told her to settle her
obligation with me in the Barangay;

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 F. Thus, I went to Barangay and waited for ____________ , unfortunately
she did not come and until now she failed and refused to settle her
obligation;

G. _____________ has still a total balance of Fifty One Thousand Eight

Hundred Forty Eight (Php. 51,848) pesos;

H. So, I decided to complain this matter with the ______________of Iloilo

City Hall for appropriate action against _______________ and to deny the
aforementioned of renewal of her employment in the ____________l.

2. I am executing this affidavit to attest to the truthfulness of the forgoing facts

in order to complain against ___________ for Conduct unbecoming as a
Government employee and to recover from her the money she borrowed
from me.

IN WITNESS WHEREOF, I affix my signature this _________ in Roxas City,

Capiz, Philippines.

________________
Affiant

SUBSCRIBED and SWORN to before me, this ___________ in the City of

Roxas, Province of Capiz, Philippines, affiant exhibiting to me her proof of identity:
_____________________.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2023.

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