Republic of the Philippines)

____________, ________ ) s.s.

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

COMPLAINT AFFIDAVIT

The UNDERSIGNED, __________________________, accuses _________, of

_____________, committed as follows, to wit:

That on or about _________, at about _____________ in the _________________,

______________, Philippines, the said accused did then and there willfully, unlawfully, feloniously, and
by means of _____________, committed _____________, upon the undersigned directly by overt acts to
wit: (state the details how the crime was committed).
The undersigned executed this affidavit to attest the truthfulness of the foregoing facts and to
support the filing of Criminal Cases against _______________________________ for violations of
________________________.

___________, this _____ day of __________, ____.

____________________________
Offended Party

SUBSCRIBED AND SWORN to before me this ___ day of _______ at _______________. I

HEREBY CERTIFY that I have personally examined the herein offended party and I am satisfied that
they voluntarily executed and understood their given affidavit.

_______________________
Prosecutor