Republic of the Philippines )

City of Makati ) s.s.

COMPLAINT-AFFIDAVIT

I, [NAME] _______________, of legal age, Filipino, with assistance of counsel, and

resident of [ADDRESS] _______________, do hereby state under oath that:

1. I am [STATE PERSONAL CIRCUMSTANCES OF COMPLAINANT-AFFIANT]

____________________________.

2. I accuse and hereby charge [NAME] __________________, residing at

[ADDRESS] _______________________, of violating Article [ARTICLE NUMBER]
_________________ of the Revised Penal Code [STATE CRIME COMMITTED], committed
against me when he publicly, maliciously and deliberately [STATE ACTS COMMITTED
CONSTITUTING THE CRIME] __________________________.

3. Prior resort to the Barangay conciliation system proved fruitless as [STATE

REASONS FOR FAILURE OF BARANGAY CONCILIATION] _____________________________.
Consequently, a Certification to File Action was issued by the Barangay Chairperson, a copy
of which is attached as ANNEX B.

4. [STATE CIRCUMSTANCES CONSTITUTING ELEMENTS OF THE CRIME]

_________________________.

5. [STATE CIRCUMSTANCES CONSTITUTING ELEMENTS OF THE CRIME]

_________________________.

6. [STATE DAMAGES AND AMOUNTS THEREOF SOUGHT, AND REASONS FOR

SEEKING SUCH] ____________________________.

TO THE TRUTH OF THE FOREGOING, I have signed this Complaint-Affidavit on

[DATE] _________________________.

[SIGNATURE]
[NAME] ______________
Complainant-Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this _________ day of [MONTH] ______

[YEAR] ___________.

[SIGNATURE]
Investigating Prosecutor

CERTIFICATION

I HEREBY CERTIFY THAT I HAVE PERSONALLY EXAMINED THE AFFIANT AND AM

SATISFIED THAT HE VOLUNTARILY EXECUTED AND UNDERSTOOD HIS AFFIDAVIT.

[SIGNATURE]
Investigating Prosecutor