COMPLAINT AFFIDAVIT

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

resident of _____________, Philippines, after being sworn to in accordance
with law, depose and state:

That I know the person of __Respondent__, who is a resident of

_____________, Philippines;

That sometime in the morning of __date of issue__, at __place of issue__,

Philippines, the said __Respondent__ issued in my favor a __Name of
Bank__ Check No. _____________ in the amount of P_____________ as
supposed payment for the loan accommodation of P_____________, which I
have extended to (him/her);

That the said check is drawn against the account of the said
__Respondent__ at __Name of Bank__ with Account No. _____________;
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 is a good check and would be covered by sufficient funds when
presented for payment;

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 "____";

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 "____"

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__ has 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 ____"

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) last known address at _____________,
Philippines;

IN WITNESS WHEREOF, I have hereunto set my hand this _____________

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.