Republic of the Philippines )

Municipality of Kalibo, Aklan ) s.s.

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COMPLAINT AFFIDAVIT

That I, _______________ , of legal age, Filipino and a resident

of Kalibo, Aklan, after having been duly sworn to according to law
hereby depose and say:

1. That I am the _____________ of Municipality of Kalibo,

Aklan. I am executing this affidavit in behalf of said
municipality, being the complainant herein;
2. In behalf of the said municipality, I am filing a formal
complaint for Violation of Section ____ of Municipal
Ordinance No. 2016-008 otherwise known as “AN
ORDINANCE PROHIBITING THE USE, SALE, DISTRIBUTION
AND ADVERTISEMENT OF CIGARETTES AND OTHER
TOBACCO PRODUCTS, AND ELECTRONIC CIGARETTES, IN
ALL PUBLIC PLACES, IMPOSING PENALTIES FOR
VIOLATIONS THEREOF AND PROVIDING FUNDS THEREFOR,
AND FOR OTHER PURPOSES” against respondent
_________, a resident of _________, _______, Aklan. A
copy of said ordinance is attached as “Annex A”;
3. That on ___________, about _____________ in the
morning/afternoon, respondent was caught smoking in
___________________. The said violation constitutes as a
first/second/third offense under abovementioned ordinance
and he/she was issued a citation ticket with Ticket No.
________________. Attached herein is a copy of the said
citation ticket as “Annex B”;
4. That respondent was informed to pay/settle his fine within
five (5) days at the Municipal Treasurer’s Office, Municipality
of Kalibo otherwise the Municipality shall be constrained to
file a case against him/her;
5. That after five (5) days upon issuance of ticket, respondent
failed to pay the fine imposed at the Municipal Treasurer’s
Office, Municipality of Kalibo;
6. That a demand letter dated __________ was sent to
respondent to require him to settle his obligation after
_____ days upon receipt. Attached herein is a copy of said
letter as “Annex C”;
7. That until now, respondent has failed to settle his obligation;
8. That I am executing this affidavit for and behalf of the
Municipality of Kalibo, being the ___________ thereof, to
file a formal complaint for Violation of Section 5(a) of
 Municipal Ordinance No. 2016-008 against
_________________.

IN WITNESS WHEREOF, I have hereunto affixed my

signature for and in behalf of the complainant Municipality of
Kalibo this ____ day of August 2018, at Kalibo, Aklan.

_______________________

AFFIANT
ID No.__________________

SUBSCRIBED AND SWORN to before me this ___ day of

_______ at _______________. I HEREBY CERTIFY that I have
personally examined the herein offended party and I am satisfied
that they voluntarily executed and understood their given
affidavit.