COMPLAINT-AFFIDAVIT

I, ________________, of legal age, Filipino, (single/married/widow), and a

resident of ______________, Philippines, after being sworn in accordance with the
law, hereby depose and state:

1. That I know the person _______________________ Respondent, who is

resident _________________, Philippines;

2. That sometime in the morning of _____________ date of issue _________,

at _________ place of issue _________________, Philippine, the said
Respondent, issued in my favor a Name of Bank, Check No.
___________________ in the amount of ₱______________ as supposed
payment for the loan accommodation of ₱_______________, which I have
extended to (him/her);

3. That the said check is drawn against the account of the said Respondent at
Name of Bank with Account No. ___________________;

4. That at the time the said Respondent issued the delivered the said check to
me, (he/she) made the assurance and representation that the said check and
would be covered by sufficient funds when presented for payment;

5. However, when the above-mentioned check was deposited, the same was
dishonored and returned by the bank on the ground that the same was drawn
against a “CLOSED ACCOUNT.” A true and faithful machine reproduction
of the said check is hereto attached as Annex “___”;

6. As such I immediately notified said Respondent of the dishonor and return

of the said check and demanded from (him/her) that (he/she) make good the
said check within_____ (____) days from receipt thereof. A true and faithful
machine reproduction of my demand letter to (him/her) is hereto attached as
Annex “____”;

7. When said Respondent failed to heed my demands, I endorsed the said check
to my legal counsel who immediately sent a formal demand letter through
registered mail with return card on _________________, which was
received by the said Respondent on ________________. As of date
however, Respondent was unjustifiably ignored all these demands to pay the
said account and/or to redeem the said returned check. A true and faithful
machine reproduction of my demand letter to (him/her) is hereto attached as
Annex “_____”;
 8. I am therefore executing this Complaint-Affidavit in support of the charges
for Violation of Batas Pambansa Bilang 22 against the said Respondent
_________________, who may be served with subpoena and other
processes of this Honorable Office at (his/her) D last known address
at_________________, Philippines.

COMPLAINANT

SUBSCRIBED AND SWORN to before me this ____________________ at

_____________. I hereby certify that I have examined the Affiant and that I am
fully satisfied that (he/she) has voluntarily executed and understood the contents of
(his/her) Complaint-Affidavit.

Contrary to law.

__________________, _______________________, 20___.

________________________
(Provincial Prosecutor)

WITNESSES:

______________________
______________________