COMPLAINT-AFFIDAVIT I, _______________________, of legal age, single, Filipino and a resident of _________________________, Tarlac City, after being sworn to in accordance

with law, depose and state that: Sometime in the morning of _____________________ in the City of Tarlac, specifically along Tarlac Sta-Rosa Road, Barangay Matatalaib, ____________________________, to be hereinafter referred to as the accused, who is a resident of _______________________, Tarlac City being then the driver of ____________________________, did then and there willfully, unlawfully and feloniously drive, manage and operate the same in a reckless, careless, negligent and imprudent manner, without regard to traffic laws, rules and regulations and without taking the necessary care and precaution to avoid damage to property and injuries to person, causing by such negligence, carelessness and imprudence the said vehicle to bump/collide with ____________________ bearing plate no. _______________ driven by me, thereby causing damage to the motorcycle which would require repair estimated at P57,000.00; As further consequence due to the strong impact, I suffered bodily injuries which required medical attendance for a period of ____ days, from ___________ to _______________, and incurred the amount of P53,000.00 as hospitalization expense. Furthermore, I was advised by my attending physician, Dr. _____________ to undergo operation on my right shoulder which would cost between P85,000.00 to P100,000.00, and not to mention the fact that I have become incapacitated from performing my customary labor since the accident; The report from the Tarlac City Police Station clearly establishes the recklessness of accused. A copy of which is attached as ANNEX A and made an integral part of this complaint. As contained in said report and going back to what had transpired, I was then cruising in a motorcycle as described above on its proper lane along the stretch of Tarlac Sta. Rosa Road heading west when suddenly the vehicle driven by the accused coming from the opposite direction (east) encroached the motorcyles lane in a vain attempt to overtake another vehicle (______________________________), and to avoid collision I in fact even tried to swerve the motorcycle to the right shoulder of the road to give much room for the accuseds vehicle to pass, notwithstanding the collision was not avoided;

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4. The collision flung the motorcycle off the road southward from the point of impact while throwing me off my seat and knocking me seemingly lifeless. Accuseds vehicle skidded southward evidencing his irresponsible and reckless act of overtaking and overspeeding. Photos of the actual collision of

the subject vehicles are attached as ANNEX B and made an integral part of this complaint;
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Therefore, the accuseds overtaking and the speed in which he drove his car appear to be the main causes for his inability to stop his car and avoid the collision. Indeed, accused, being the driver of an overtaking vehicle, should have ensured that the conditions were such that an attempt to pass is reasonably safe and prudent, and in passing should have exercised reasonable care, which he failed to do so, thus, he should be made liable for the resulting damages to the motorcycle and for the injuries I sustained; I am therefore executing this Complaint-Affidavit in support of the charges for Reckless Imprudence Resulting in Serious Physical Injuries and Damage to Property against the said Accused.

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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 has voluntarily executed and understood the contents of his Complaint-Affidavit.

Administering Officer