Dumapias, Darleene Rae A.

Legal Counseling
IV- Teehankee March 13, 2019

Republic of the Philippines )

City of Iligan ) S.s.
x-------------------------------------x

COMPLAINT-AFFIDAVIT

I, JUAN DELA CRUZ, of legal age, residing at Purok 9 Bayug, Brgy. Hinaplanon,
Iligan City, after having sworn in accordance with law, do hereby depose and declare
that:

1. Last March 2, 2019, at around ten o’clock in the evening (10 p.m), I, together
with my friends Du Kaon, Way Tulog and Sig Kape, went to 7/11 Tibanga to
drink coffee;
2. After purchasing our coffee, we went outside the store to occupy the empty table
and chairs;
3. On the way to the table, I tripped and accidentally spilled the entire cup of hot
coffee to Walang Tawad who was standing outside 7/11 Tibanga;
4. I immediately apologized and offer to compensate him for the stained shirt;
5. Despite my apology, Walang Tawad got furious and took Sig Kape’s cup of hot
coffee and threw its content on my face;
6. Shocked, I was not able to avoid it and the hot coffee splashed on the right side
of my face, hitting my right eye and right ear;
7. I was immediately rushed to Adventist Medical Center for medical treatment. The
hospital found out that my right eye got burned resulting to loss of vision or
blindness. The copy of the Medical Certificate is hereto attached as Annex “A”;
8. I stayed in the hospital for ten (10) days and incurred medical expense. The
copy of the Billing Statement is hereto attached as Annex “B”;
9. A written statement by Du Kaon, Way Tulog and Sig Kape dated March 10, 2019
that they witnessed what transpired last March 2, 2019 is hereto attached as
Annex “C”;
10. I am executing this affidavit to attest to the truth of the foregoing statements
and for the purpose of charging Walang Tawad with the crime of Serious
Physical Injuries. I am also holding Walang Tawad civilly liable to me in the
amount of Two Hundred Thousand Pesos (P200,000.00) for actual damages,
Five Hundred Thousand Pesos (P500,000.00) in moral damages and Five
Hundred Thousand Pesos (P500,000.00) in exemplary damages.

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Dumapias, Darleene Rae A. Legal Counseling
IV- Teehankee March 13, 2019

IN WITNESS WHEREOF, I have hereunto affixed my signature this 13th

day of March 2019 at Iligan City.

JUAN DELA CRUZ

Complainant-Affiant

SUBSCRIBED AND SWORN to before me, the undersigned prosecutor, this 13th
day of March, 2019, in the City of Iligan, Philippines

The undersigned Prosecutor certifies that he personally examined the affiant and
that he is satisfied that the affiant voluntarily executed and understood the complaint-
affidavit.

PEDRO PENDUKO
Investigating Prosecutor

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