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 atatalaib, ____________________________, to be hereinafter referred to as the acc!sed, who is a resident of _______________________, Tarlac City being then the dri"er of ____________________________, did then and there willf!lly, !nlawf!lly and felonio!sly dri"e, manage and operate the same in a rec#less, careless, negligent and impr!dent manner, witho!t regard to traffic laws, r!les and reg!lations and witho!t ta#ing the necessary care and preca!tion to a"oid damage to property and in$!ries to person, ca!sing by s!ch negligence, carelessness and impr!dence the said "ehicle to b!mp%collide with ____________________ bearing plate no& _______________ dri"en by me, thereby ca!sing damage to the motorcycle which wo!ld re'!ire repair estimated at ()*,+++&++, -s f!rther conse'!ence d!e to the strong impact, I s!ffered bodily in$!ries which re'!ired medical attendance for a period of ____ days, from ___________ to _______________, and inc!rred the amo!nt of ().,+++&++ as hospitali/ation e0pense& F!rthermore, I was ad"ised by my attending physician, 1r& _____________ to !ndergo operation on my right sho!lder which wo!ld cost between (2),+++&++ to (3++,+++&++, and not to mention the fact that I ha"e become incapacitated from performing my c!stomary labor since the accident, The report from the Tarlac City (olice Station clearly establishes the rec#lessness of acc!sed& - copy of which is attached as -4456 7-8 and made an integral part of this complaint& -s contained in said report and going bac# to what had transpired, I was then cr!ising in a motorcycle as described abo"e on its proper lane along the stretch of Tarlac Sta& Rosa Road heading west when s!ddenly the "ehicle dri"en by the acc!sed coming from the opposite direction 9east: encroached the motorcyle;s lane in a "ain attempt to o"erta#e another "ehicle 9______________________________:, and to a"oid collision I in fact e"en tried to swer"e the motorcycle to the right sho!lder of the road to gi"e m!ch room for the acc!sed;s "ehicle to pass, notwithstanding the collision was not a"oided,

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<& The collision fl!ng the motorcycle off the road so!thward from the point of impact while throwing me off my seat and #noc#ing me seemingly lifeless& -cc!sed;s "ehicle s#idded so!thward e"idencing his irresponsible and rec#less act of o"erta#ing and o"erspeeding& (hotos of the act!al collision of

the s!b$ect "ehicles are attached as -4456 7B8 and made an integral part of this complaint,
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Therefore, the acc!sed;s o"erta#ing and the speed in which he dro"e his car appear to be the main ca!ses for his inability to stop his car and a"oid the collision& Indeed, acc!sed, being the dri"er of an o"erta#ing "ehicle, sho!ld ha"e ens!red that the conditions were s!ch that an attempt to pass is reasonably safe and pr!dent, and in passing sho!ld ha"e e0ercised reasonable care, which he failed to do so, th!s, he sho!ld be made liable for the res!lting damages to the motorcycle and for the in$!ries I s!stained, I am therefore e0ec!ting this Complaint--ffida"it in s!pport of the charges for Rec#less Impr!dence Res!lting in Serio!s (hysical In$!ries and 1amage to (roperty against the said -cc!sed&

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IN WITNESS WHEREOF, I ha"e here!nto set my hand this _____________ at _____________, (hilippines&

COMPLAINANT

SUBSCRIBED AND SWORN to before me this _____________ at _____________& I hereby certify that I ha"e e0amined the -ffiant and that I am f!lly satisfied that he has "ol!ntarily e0ec!ted and !nderstood the contents of his Complaint--ffida"it&

-dministering =fficer