Republic of the Philippines)

Province of ____________) S.S.

Municipality of __________)

COMPLAINT-AFFIDAVIT

I, _____________, of legal age, __________________, with office address at

__________________________, under oath, state: THAT--

1. I am the ___________________________________ (‘Complainant’, for brevity), a

mining corporation duly organized and existing under the laws of the Republic of
the Philippines, with site office address at ________________________________.

Complainant may be served with subpoena and other processes of the Honorable
Office of the Provincial Prosecutor, _____________________, at the address
above stated.

2. Respondents ________________________________.
________________________ where they may be served with subpoenas and
other processes of the Honorable Office of the Provincial Prosecutor,
___________________ relating to the instant complaint.

________________________________________________________________.

3. I am the duly authorized representative of the complainant to file a complaint

against ________________________________________ ('Respondents', for
brevity) by virtue of a Secretary’s Certificate dated __________________ which is
attached hereto as Annex “B.

4. Based on the _______________________________________ is hereto attached

as Annexes C, said criminal offense was committed as follows:

a. _________________________________________________________.
b. _________________________________________________________.
c. _________________________________________________________.
d. _________________________________________________________.
e. _________________________________________________________.

5. I am executing this complaint-affidavit to attest to the truth of the foregoing facts

and to file a complaint against respondents
_______________________________for ________________ or such other
criminal offenses which the Honorable Provincial Prosecutor may deem appropriate
under the premises.
 IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of
______________, 2019, in _________________________.

____________________________
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of ___________, 2019, in

__________________________.

______________________
Administering Officer

I HEREBY CERTIFY that I have personally examined the affiant and I am fully
satisfied that he read and understood the contents of his complaint-affidavit and that he
voluntarily executed the same.

______________________
Administering Officer