REPUBLIC OF THE PHILIPPINES

REGIONAL TRIAL COURT

BRANCH ________, PALAYAN CITY

PEOPLE OF THE PHILIPPINES

-versus- Criminal Case

No. ________________________
For: RAPE

MARIO _____________________,
Accused.
x---------------------------------------------x

COMPLAINT AFFIDAVIT

I, Marissa, 12 years old, single, Filipino, and a resident of 122 Atate, Palayan City, Nueva
Ecija, after having sworn in accordance with law, despise and state that:

1. The accused in this case is my cousin, Mario, a resident of 123 Atate, Palayan City,
Nueva Ecija;
2. On March 1, 2018, I woke up as I felt the accused’s hands on my legs. I was not scared
at first but when he started caressing my hips and breasts I started crying as the accused
threatened to hurt me if I resisted. He slid his hands inside my panty and inserted his middle
finger in my vagina. I cried ever more because what he did really hurt me. After a few
moments he suddenly stopped and quickly left our house;
3. I immediately told my mother what happened and we went to a hospital. According
to the doctor, I suffered fresh slight lacerations inside my vagina as evidenced by a medical
certificate hereto attached as Exhibit “A”;
4. I am executing this Complaint-Affidavit to attest the truth of the foregoing and in
support of the appropriate criminal charges against the accused for Rape under Article 266-
A of the Revised Penal Code, as amended.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my signature this
__________________________, in Talavera, Nueva Ecija.

MARISSA
Complainant

Under the guidance of

__________________
Mother of the complainant

SUBSCRIBED AND SWORN TO before me this ____________________, in Talavera,

Nueva Ecija, affiant exhibiting to me his competent evidence of identity.

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ATTESTATION

I, ATTY. _________________________________________, with office address at Palayan,

Nueva Ecija, hereby attest under oath that:

I personally conducted the interrogation of Marissa 122 Atate, Palayan City, Nueva
Ecija, the complainant in the above-captioned case. I have faithfully recorded the questions I
asked Ms. Marissa and the corresponding answers she gave me and neither I nor any other
person then present coached Ms. Marissa regarding her answers.

ATTY. ___________________________
Affiant
IBP No.

SUBSCRIBED AND SWORN TO before me this _________________, in

___________________________.

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