Republic of the Philippines

SUPREME COURT
Manila

En Banc

[NAME]__________,
Petitioner,
Copy No. ___________
- versus -

[NAME]__________,
Respondent.
x ----------------------------------- x

PETITION FOR REVIEW ON CERTIORARI

PETITIONER, by counsel, respectfully states that:

I.
PREFATORY STATEMENT

This is an appeal under Rule 45 of the Rules of Court from the Decision of the Court of
Appeals ( _______ Division) dated ____________ in CA-G.R. CR-HC No. ________ entitled
“_______________.” A certified copy of the said Decision in question is hereto attached as
Annex A and is hereinafter referred to as the CA Decision for brevity.

II.
STATEMENT OF MATERIAL DATES

Notice of the said CA Decision was received by herein lead counsel on ________. The
15-day reglementary period for a petition under Rule 45 ends on __________ [IF WEEKEND,
INDICATE THAT IT SHALL BE MOVED TO THE NEXT WORKING DAY].

III.
PARTIES

[ADD DESCRIPTION OF THE PETITIONER]

[ADD DESCRIPTION OF THE RESPONDENT]

IV.
CONCISE STATEMENT OF THE MATTERS INVOLVED

[PROVIDE A BRIEF STATEMENT OF THE MATTERS INVOLVED]

V.
DISCUSSION

[PROVIDE THE DISCUSSION OF THE MATTERS INVOLVED]

V.
PRAYER FOR RELIEF

WHEREFORE, it is respectfully prayed that this Honorable Court:

 a) Declare as void the Decision of the Court of Appeals (________ Division) in CAG.R.
CR HC No. _________ dated ________ for _____________;
b) [INDICATE OTHER RELIEFS]

[CITY] ___________; [DATE] _________________________.

[SIGNATURE]
[NAME OF COUNSEL] ___________
Counsel for Petitioner
[ADDRESS] ______________

VERIFICATION & CERTIFICATION AGAINST FORUM SHOPPING AND VERIFIED STATEMENT

OF MATERIAL DATES

I, Plaintiff, of legal age, do hereby state that: I caused this Complaint to be prepared;
I have read its contents and affirm that they are true and correct to the best of my own personal
knowledge; I hereby certify that there is no other case commenced or pending before any
court involving the same parties and the same issue and that, should I learn of such a case, I
shall notify the court within five (5) days from my notice.

I received copy of [ORDER/DECISION] ____________ on [DATE] _____________; and

I filed a Motion for Reconsideration on [DATE] ____________________; and the Motion for
Reconsideration was denied and I received a copy on [DATE] _________________.

IN WITNESS WHEREOF, I have signed this instrument on [DATE]_____________.

[SIGNATURE]
[NAME] _________________

SUBSCRIBED AND SWORN TO before me in the City of _______________ on this day

of [MONTH AND YEAR]_________________, affiant exhibiting before me his Government
Issued ID no. _______________ issued on [DATE}__________________ at [PLACE OF
ISSUANCE]_____________________.

[SIGNATURE]
[NAME]_______
Notary Public

Until [DATE]__________________
PTR No. [NUMBER] ____________
Issued at [PLACE]______________
On [DATE] ___________________

Doc. No.
Page No.
Book No.
Series of [YEAR] ___________.