N.B.

: This form shall serve only as a guide and may be in a language or dialect known to the
complainant-affiant.

Republic of the Philippines )
_____________________ ) S.S.

AFFIDAVIT

I, __________________, single/married,
____ years old, presently residing at
_________________________, under oath,
do hereby depose and state that:

1. I have a savings/time/current account
deposit with _________________Bank,
_______________ Branch, with office
address at ________________________.
The said deposit is designated as Account
No. __________________ and has a
balance of ________________________
(Php ________________) as of
____________________, 20__.

2. (State WHAT is the incident being
complained of, WHEN and WHERE it
happened.)

3. (Describe HOW the incident transpired.)

4. (If known, state the name or identity of the
alleged perpetrator of the incident
complained of and that persons position in
the bank.)
5. (If likewise known, state WHY the incident
happened.)

6. (If any, state the name or identity of the
witnesses to the incident or the persons
who may be able to attest thereto.)

Republika ng Pilipinas)
_________________ ) S.S.

SINUMPAANG SALAYSAY

Ako, si ___________________, walang
asawa/may asawa, ____ taong gulang,
kasalukuyang naninirahan sa
_______________________, pagkatapos
makapanumpa ng naaayon sa batas, ay
malayang nagsasaysay na:
1. Ako ay may savings/time/current account
deposit sa ____________________ Bank,
_________________ Branch na
matatagpuan sa ______(ADDRESS)__.
Ang nasabing deposito ay may Account
No. _________________________ at may
balanseng nagkakahalaga ng
_______________________ (Php
________) noong ________________.


2. (Isalaysay kung ANO ang insidenteng
inirereklamo, KAILAN at SAAN ito
naganap)


3. (Isalaysay kung PAANO naganap ang
insidente.)

4. (Kung kilala, isalaysay kung SINO ang may
kagagawan ng insidenteng inirerekklamo
at ano ang posisyon niya sa Bangko.)

5. (Kung alam din, isalaysay kung BAKIT
naganap ang insidente)

6. (Kung mayroon, isalaysay kung sino-sino
ang nakakita sa insidente o kasama nang
maganap ang insidente o
makapagpapatunay nito.)
7. (If any, state the documents that may
prove the incident and attach copies
thereof to the affidavit.)

8. I have not commenced any action or filed
any claim involving the same issues before
the BSP or any court, tribunal or quasi-
judicial agency and, to the best of my
knowledge, no such other action or claim
is pending therein. (If there is a similar
case or action, full disclosure of the status
of the same should be done. The following
details should be provided: the
court/tribunal/government agency where
the action/claim is filed; nature of
action/claim; parties; date action/claim was
filed; etc.)

9. If I should thereafter learn that a similar
action or claim has been filed or is pending
before a court. tribunal or agency, I
undertake to report that fact within five (5)
days therefrom to PDIC.

10. (Include only if the complaint involves a
deposit in the bank) By reason of the fact
that my deposit with Account No.
_____________ is involved in this
complaint, I am expressly authorizing
PDIC and/or any of its duly-authorized
representatives to examine all the records
of the said deposit account and secure
copies thereof in accordance with the
exception provided for under Republic Act
No. 1405 (Law on Secrecy of Bank
Deposits).

11. I am executing this affidavit to attest to
the truth of the foregoing and for whatever
legal purpose it may serve.

12. At the moment, affiant further sayeth
naught.


7. (Kung mayroon, sabihin kung anu-anong
mga dokumento ang magpapatunay sa
mga nakasaad sa itaas at maglakip ng sipi
o kopya nito sa salaysay.)

8. Ako ay walang ibang isinampang reklamo
sa anumang hukuman o tanggapan laban
sa nabanggit na bankgo at mga tao hinggil
sa pangyayaring nakasaad sa itaas, at sa
aking pagkakaalam ay walang ibang
kasong katulad ng reklamong ito ang
nakasampa kung saan man. (Kung
mayroong nakasampang kasong
kahalintulad ng reklamong ito, dapat isaad
ang mga detalye nito tulad ng hukuman o
tanggapang pinagsampahan, kailan
isinampa, sino ang mga partido, ano ang
kasong isinampa, atbp.)

9. Ipinangangako ko na kung malalaman ko
na mayroong kaso o reklamong
kahalintulad nito ang nakasampa sa
anumang hukuman o tanggapan ay
ipaaalam ko ito sa PDIC sa loob ng limang
(5) araw.

10. (Ilagay kung ang reklamo ay nakabatay sa
deposito sa bangko) Sa kadahilanang ang
reklamong ito ay nakabatay sa nabanggit
na deposito ko na may Account No.
___________ sa naturang bangko, aking
hayagang pinahihintulutan ang PDIC o
sinumang kinatawan nito na suriin ang
lahat ng rekord o talaan ng aking deposito
at makakuha o makapagpakopya ng
anumang dokumento o rekord/talaan
hinggil dito ayon sa liban o exception na
nakasaad sa Republic Act No. 1405 (Law
on Secrecy of Bank Deposits).

11. Isinasagawa ko ang salaysay na ito upang
patotohanan ang lahat ng nakasaad sa
itaas at para sa anupamang kadahilanang
naaayon sa batas.

12. Sa ngayon, ay wala na akong nais pang
sabihin.

IN WITNESS WHEREOF, I have hereunto set
my hand this ____ day of __________, 20___,
in ________________, Philippines.



_______________
Affiant

SUBSCRIBED AND SWORN to before me
this ____ day of ____________, 20___, in
_____________, Philippines, with the affiant
exhibiting his/her Community Tax Cert. No.
______________, issued on
_______________, at ________________.



Notary Public

Doc. No. ______
Page No. ______
Book No. ______
Series of 20___.

BILANG KATUNAYAN NG LAHAT, ako ay
lumalagda ngayong ika-___ ng
_____________, 20__, sa
________________, Pilipinas.



_________________
Nagsasaysay

SINUMPAAN AT NILAGDAAN sa harap ko
ngayong ika-____ ng ________________,
20__, sa ____________________________,
at ipinakita sa akin ng nagsasaysay ang
kanyang Community Tax Cert. No.
_____________, na ipinagkaloob noong
____________________, sa
_________________________.

Notaryo Publiko


Doc. No. _______
Page No. _______
Book No. _______
Series of 20___.