Republic of the Philippines

Department of Justice

CITY PROSECUTION OFFICE

COMPLAINT AFFIDAVIT

I___________________, of legal age, Filipino, married to the respondent, and a resident of

__________________, after having been duly sworn in accordance with law, hereby depose and
state:

1. I am and the same person who is the complaint in the instant case;
2. I know the person of __________, being my husband and who is currently in
___________, where he may be served with _____________;
3. That we are married on_______________at _________________. The copy of
marriage certificate is hereto attached as Annex A;
4. That out of our lawful marriage, we begot ________child(ren). This first child is
_____________ was born on ___________ and our second child was born on
___________. Copies of their Certificate of Live Birth are hereto attached and
marked as Annexes and respectively;
5. That in the beginning of our marriage, we lived harmoniously as husband and wife
and parents to our children until later part that my husband had shown and
displayed irrational behavior not expected from a mature and a responsible
husband and father to our children;
6. That while he was in ________________, he used to regularly go home and visit us;
7. That when he _______________..., worst is he did not even send support to us;
8. That I have sent a letter to. Requesting for sub-allotment of allowances intended
for own ( 2 ) children, copy of which is hereto attached as Annex .
9. I was constrained to seek legal assistance from Carillo Law Centrum which
immediately assisted me by preparing and sending a Demand Letter requesting
theat the amount of _______Pesos shall be directly deducted from the net pay of
my husband and the amount be sent to me in a form of a check. The same request is
not yet acted upon until this very moment, copy of the said letter is hereto attached
and marked as Annex .
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11. That his act of continuous failure to give support since the year____ tantamount to
economic abuse which is defined under R.A. 9262 or Violence Against Women and
their Children as:
12. I have been hearing rumors that my husband has been romantically engaged and
cohabiting with another woman in____... Such act caused substantial and emotional
distress to me and our children which is a violation of paragraph (h) Section 5 of R.A.
9262;
13. Moreover, we suffer and continuously suffering of mental and emotional anguish,
public ridicule and humiliation when he cohabits with another woman and failed to
provide financial support to our family which is a violation of paragraph (i) Section 5
of R.A. 9262;
14. That I cause the preparation of this affidavit to support my complaint.
IN WITNESS WHEREOF, I have hereunto set my hand this________________
at_______________, Philippines.

___________________________

Complainant-Affiant