REPUBLIC OF THE PHILIPPINES

OFFICE OF THE CITY PROSECUTOR

Quezon City
Romeo,
Complainant,

I.S. No. 0123456

For: Estafa and BP Blg.

22
-versusJuliet,
Respondent,
x--------------------------------x
COMPLAINT-AFFIDAVIT
I, Romeo, of legal age and a resident of No. 8 Rizal Avenue, Binondo, Makati City, under
oath declare that:
1. That I am filing a complaint against Juliet for Estafa and for violation of BP 22 who can
be served with summons and notices at _____________________________.
2. That sometime on _____________________________________ at my residence in the City of
Makati, Juliet went to my house to borrow money in the amount of _________________
for the rehabilitation and maintenance of her pawnshop as evidenced by our contract of
loan marked as Annex A;
3. That on the same
_____________________;

day,

lent

her

____________________

payable

until

4. That Juliet issued a check payable to me which is the subject of this case in the
amount of _____________________ dated _____________________ numbered as
____________________ herein marked as Annex b;
5. That on the dates of the check I deposited the same and to my dismay they all came
back with annotations ACCOUNT CLOSED.
6. That she defrauded me to part with my money when he issued a check and knowing
very well that the same is worthless;
7. That upon bouncing of the checks I PERSONALLY delivered a demand letter to the
respondent giving her a chance to make good the payments of the checks but she
chose to ignore the same;
8. Herein attached is the demand letter delivered personally to the respondent on
_______________, 2014 as Annex C;
IN WITNESS WHEREOF, I have affixed my signature this _______ day of _________, 2014
in _________________, Philippines.
________________________________
Complainant
SUBSCRIBED AND SWORN to before me this ______ day of ___________,2011 in __________.
I further certify that I have personally examined the Affiant and I am satisfied that she
voluntarily executed her Counter-Affidavit and that she understood the contents of the same.

1|Page

ADMINISTERING OFFICER
REPUBLIC OF THE PHILIPPINES
OFFICE OF THE CITY PROSECUTOR
Quezon City
Romeo,
Complainant,

I.S. No. 0123456

For: Estafa and BP Blg.

22
-versusJuliet,
Respondent,
x--------------------------------x
COUNTER-AFFIDAVIT
I, Juliet, of legal age and a resident of No. 8 Rizal Avenue, Binondo, Makati City, under
oath declare that:
1. I am the respondent in I.S. No. 0123456 for Estafa and Violation of BP 22;
2. I admit the allegations in Paragraph ___________________ of the Complainants
Complaint Affidavit;
3. I deny the allegations in Paragraph ____________________ for claiming that the defendant
after notice of the dishonored check practically abandoned to fund it. Respondent
through letter replied dated _____________________ stating that she was not able to fund
the said check due to the series of losses suffered by her business referred as annex 1;
4. Respondent rejects also the contention of the complainant that she employed deceit in
the issuance of dishonored check.

IN WITNESS WHEREOF, I have affixed my signature this _______ day of _________, 2014
in _________________, Philippines.
________________________________
Complainant

SUBSCRIBED AND SWORN to before me this ______ day of ___________,2011 in __________.

I further certify that I have personally examined the Affiant and I am satisfied that she
voluntarily executed her Counter-Affidavit and that she understood the contents of the same.

ADMINISTERING OFFICER

2|Page