Republic of the Philippines

MUNICIPAL CIRCUIT TRIAL COURT

_______________, CEBU
PEOPLE OF THE PHILIPPINES
Plaintiff,

CRIM. CASE NO. ________

FOR: SLIGHT PHYSICAL INJURIES

-versus_____________________________
_____________________________
Defendant,
x - - - - - - - - - - - - - - -- - - - - - - - - - /
Republic of the Philippines)
Province of Cebu

) S.S.
JUDICIAL AFFIDAVIT

I,

______________________________,

of

legal

age,

residing

at

________________________________________ after having duly sworn to in

accordance with law do hereby depose and state; that,
1. Where were you on (time and place of incident)?
______________________________________________________________________
______________________________________________________________________
2. What

were

you

doing

on

that

particular

time

and

place?

______________________________________________________________________
______________________________________________________________________
3. Was there any unusual incident that occurred on (time and place of
incident)?
______________________________________________________________________
______________________________________________________________________
4. What was that unusual incident that occurred?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
5. Did you report the incident to the police?
______________________________________________________________________
______________________________________________________________________

6. Do you have a copy of the police report about the incident?

______________________________________________________________________
______________________________________________________________________
7. After the incident, did you seek medical intervention?
______________________________________________________________________
_____________________________________________________________________
8. Do you have a copy of your medical certificate?
______________________________________________________________________
______________________________________________________________________

9. Do you have grudges against the accused?

______________________________________________________________________
______________________________________________________________________
10. Were you forced to testify against the accused?
______________________________________________________________________
______________________________________________________________________
11. Will you be able to identify the accused inside this court room?
______________________________________________________________________
______________________________________________________________________

IN WITNESS WHEREOF, I hereunto affix my signature this _______ day of

__________ 2012 Cebu City, Philippines.

____________________________
Affiant

SUBSCRIBED AND SWORN to me before this _____ day of __________ 2012

at __________, Cebu, Philippines.

____________________________
Officer in charge