Republic of the Philippines )

____________________________ ) S. S.
x-----------------------------------x

COMPLAINT AFFIDAVIT

I, ________________________________, Filipino, of legal age, with postal

address at _____________________________________________ , after being duly sworn
in to accordance with law, hereby depose and say:

1. That I am filing a complaint against

__________________________________ for Estafa and for violation of BP 22, who can be
served with summons and notices at
_________________________________________________________________.

2. That sometime on _________________________ at my residence in

the City of Manila, _____________________________ convinced me to take her check for
rediscounting representing that the checks will be good on the date indicated on the checks.

3. That the respondent delivered several checks and TWO (2) among
several checks are the subject of this case amounting to P235,000.00, to wit:

_____________________ BANK (Annex A) 03xxxxxx May 20,

2011 P58,750.00

_____________________ BANK (Annex B) 03xxxxxx June 20,

2011 P58,750.00

_________
___________
TOTAL:
P117,500.00
 4. That on the dates of the check I deposited the same and to my dismay
they all came back with annotations ACCOUNT CLOSED.

5. That she defrauded me to part with my money when he issued a check

with insufficient funds and worse account closed. She issues checks knowing very well that
the same is worthless.

6. That upon bouncing of the checks I PERSONALLY delivered a demand

letter to the respondent giving her a chance to make good the payments of the checks but
she chose to ignore the same.

7. Herein attached is the Demand Letter delivered personally to the

respondent on ____________, 2011 as ANNEX C.

IN WITNESS WHEREOF, I have affixed my signature this ___ day of ____________

2011 in _________________, Philippines.

_________________________________

Complainant

SUBSCRIBED AND SWORN to before me this ______ day of ___________,2011 in __________. I

further certify that I have personally examined the Affiant and I am satisfied that she voluntarily executed her
Counter-Affidavit and that she understood the contents of the same.

ADMINISTERING OFFICER

Note: Sample Only, Should be used with caution, forms are case to case basis, care should

be made in using legal forms that suit your needs.

 (Complaint Affidavit for Filing of BP 22 Case)

COMPLAINT-AFFIDAVIT

I, _____________, Filipino, of legal age, (single / married / widow), and a resident of

_____________, Philippines, after being sworn to in accordance with law, depose and
state:

That I know the person of __Respondent__, who is a resident of _____________,

Philippines;

That sometime in the morning of __date of issue__, at __place of issue__, Philippines,

the said __Respondent__ issued in my favor a __Name of Bank__ Check No.
_____________ in the amount of P_____________ as supposed payment for the loan
accommodation of P_____________, which I have extended to (him/her);

That the said check is drawn against the account of the said __Respondent__ at
__Name of Bank__ with Account No. _____________;

That at the time the said __Respondent__ issued the delivered the said check to me,
(he/she) made the assurance and representation that the said check is a good check
and would be covered by sufficient funds when presented for payment;

However, when the above-mentioned check was deposited, the same was dishonored
and returned by the bank on the ground that the same was drawn against a "CLOSED
ACCOUNT".A true and faithful machine reproduction of the said check is hereto
attached as Annex "____";

As such, I immediately notified said __Respondent__ of the dishonor and return of the
said check and demanded from (him/her) that (he/she) make good the said check within
_____________ (____) days from receipt thereof. A true and faithful machine
reproduction of my demand letter to (him/her) is hereto attached as Annex "____"

When said __Respondent__ failed to heed my demands, I endorsed the said check to
my legal counsel who immediately sent a formal demand letter through registered mail
with return card on _____________, which was received by the said __Respondent__
on _____________.As of date however, __Respondent__ has unjustifiably ignored all
these demands to pay the said account and/or to redeem the said returned check. A
true and faithful machine reproduction of my demand letter to (him/her) is hereto
attached as Annex ____"

I am therefore executing this Complaint-Affidavit in support of the charges for Violation

of Batas Pambansa Bilang 22 against the said __Respondent__, who may be served
with subpoena and other processes of this Honorable Office at (his/her) last known
address at _____________, Philippines;

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at

_____________, Philippines.

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 (he/she)
has voluntarily executed and understood the contents of (his/her) Complaint-Affidavit.

Administering Officer