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Annex B:



I, _____________________, of legal age, single/married, presently residing at

__________________________, after having duly sworn to in accordance with the
law do hereby depose and state:

That this ____ day of _____, 2016, I voluntarily went to the ________(Police
unit)__________, located at __________________ to personally submit myself or
surrender as user/pusher of SHABU/MARIJUANA;

That I used SHABU/MARIJUANA since _______ because of

_____(reasons)_____ but I decided to stop using it and I will promise not to use and
get involved in illegal drugs activities again;

That I will voluntarily give information as my commitment to pledge support in

the crusade against illegal drugs of the government particularly the PNP;


That before my voluntary submission to this authority, in several occasions, I

used to buy SHABU/MARIJUANA from (pushers name with address and other
personal circumstances);

That sometimes I would go to a drug den managed by (name with other

personal circumstances) located at ______________________________. When I
would arrive thereat, there were about ________ individuals taking illegal drugs. I
saw __________________(names)________________ also inside the den. The den
usually operates at _____(time/period)_____;

That, on several occasions, I saw ____(Police officer/ PDEA agent/

military)___ within the vicinity of the drug den;

That I also learned that their supply of illegal drugs came from a drug
laboratory located in ______(place)______ which is operated by a certain (name
with other personal circumstances). Accordingly, It existed since 2015 and never
been detected by the PDEA or the Police due to its strategic location that is hard to
find. I heard, it is located at the basement;

That some pushers operating in our place are dangerous because they are
armed with firearms. I knew _____(names with other personal circumstances)____
have their caliber .45 pistols. They are determined to kill anyone who will hinder from
their illegal activities;

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That SHABU in our place is worth ____________ pesos per gram. Pushers
prefer cash transaction but sometimes they allow swap of valuable items like
cellphones, laptops and jewelries for illegal drugs;

That I am willing to give any additional information or supplement the above

statements when I recall everything;

That, I executed this affidavit to attest the truthfulness of the above narrated
facts and to support my full interest to surrender. I hereby affix my signature this
_____ day of ______, 2016 at ________________________________.


SUBSCRIBED AND SWORN to before me this ____ day of ___________,

2016 at ___________________________. Further, I certify that I personally
examined the herein affiant that he voluntarily executed and fully understood his

Administering Officer

NOTE: This only serves as a guide and questioning may not be limited only to
elicit voluntary information found herein.

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