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Republic of the Philippines

..... ) s. s.
AFFIDAVIT
That I, ______________________________ (First/Middle/Surname), Filipino, of legal age,
single/married/widow/widower, with Philippine postal/permanent address ____________________________________
_______________________________________________________________under oath, depose and state that:
1.That
a. I am applying on my behalf
b. I am applying on behalf of (Name of Victim) ________________________________ who was a victim of human
rights violation committed on (date) ________________________ at (place) ___________________________
That attached hereto are the following documents:
ANNEX A, S.P.A. in the case where the victim is physically incapacitated or is unable to appear due to detention
or incarceration or involuntary disappearance
ANNEX B, proof of death of the victim
ANNEX C, SPA signed by the other surviving legal heirs.
ANNEX D, proof of filiation (in cases of death, mental or psychological incapacity of the victim)
2. That the human rights violation/s committed against me/ (name of victim)___________________________________
was/were perpetrated by
a. State Agent
by (name, organization, institution) ______________________________________________________
on (date) ___________________________________ or thereabouts
at (place)___________________________________________________________________________
b. Private Individuals
by (name, organization, institution) ______________________________________________________
on (date) ___________________________________ or thereabouts
at (place) ___________________________________________________________________________
That such act by these private individuals/groups are with authorization, support, or acquiescence of the State
as proved by the documents/evidence attached hereto (ANNEX E)
3.That the human rights violation/s was/were committed against me/ (name of victim)__________________________
through any of the following:
a. Death/involuntary disappearance of (name of victim) ________________ which occurred on _______________
or thereabouts, under the following circumstances:_________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
b. Torture/Rape/Sexual Abuse which occurred on __________________ until __________________ or thereabouts
under the following
circumstances:_______________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
c. Illegal detention/Arrest/Search which occurred on __________________ until _____________________ under
the following
circumstances:_______________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
d. Involuntary exile from the Philippines to ____________________from ________ until _______ under the
following circumstances:_______________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

e. Deprivation of property by confiscation/illegal takeover of my/his/her business/ livelihood under the following
circumstances:______________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
f. Any of the following act/series of acts:
i.
Kidnapping/exploitation of (name of child/children)
_____________________________________________ ________________________________ who
was/were child/children of those suspected of committing acts against the Marcos Regime under the
following circumstances:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________
ii.
Sexual offense/s against the detained in the course of conducting military/police operations under the
following circumstances: _______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
iii.
Other analogous abuses/violations to those mentioned in f.i and f.ii above:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
That attached hereto as ANNEX F are documents which corroborate these human rights violations committed
upon my person/(name of victim)________________________________________________
4. That I warrant that I am the legally authorized representative of all the living legal heirs of the claimants under pain of
prosecution of perjury and existing penal laws.

5. That I have executed this affidavit to attest to the truth of the foregoing and for other legal purposes.

IN WITNESS WHEREOF, I hereunto affix my signature this ____ day of ____________________, 2014, in
____________________________________, in the Philippines.

_________________________________
(Signature of Affiant)

SUBSCRIBED AND SWORN TO before me, in the city/municipality of _______________________, this (day)
______ of (month) __________, 20 __ by _______________________________________ with Community Tax
Certificate No. _______________ issued at (place) ____________________ on (date) _________________, 2014.

________________________________
NOTARY PUBLIC

Doc. No. _______________


Page ____________;
Book _____________
Series of 2014