REPUBLIC OF THE PHILIPPINES }

PROVINCE OF BULACAN }S..S.

CITY OF SAN JOSE DEL MONTE }

JUDICIAL AFFIDAVIT

I, _____________________________, ____ year old, married/single/widow,

___(occupation)___ and a resident of _____________________________, after subscribing
under oath, deposes and states:

That Prosecutor _______________________, detailed at the Office of the City

Prosecutor, San Jose Del Monte City, Bulacan, 2/F Cangayo Bldg., Brgy. Gaya Gaya, this City,
conducts/supervises the examination of the affiant hereat the Office of the City Prosecutor, San
Jose Del Monte City;

That the undersigned affiant-witness is answering the questions asked of him/her, fully
conscious that he/she does under oath, and that he/she may face criminal liability for false
testimony or perjury;

Questions asked of the witness are as follows:

1. Q: Miss witness, are you the same complainant-witness in this case against the accused
_________________?
A: ____________________________

2. Q: On November 3, 2011, at around 9:00 oclock in the evening, where were you?
A: ____________________________

3. Q: While inside your said house, do you recall having been visited by a friend?
A:____________________________

4. Q: What is the name of that friend of yours who visited you?

A: ____________________________.

5. Q: Will you kindly tell us why she visited you?

A: ____________________________.

6. Q: After she told you her purpose in coming to your house, what else did she tell you?
A: ______________________________.

7. Q: What was your reply to her invitation to you?

A: _________________________________________________

8. Q: Were you able to reach her house?

A: ________________________________.

9. Q: Where is her house located?

A: ________________________________.

10. Q: While joining the celebration, do you recall of any untoward incident that happened?
A: ________________________________.

11. Q: After this male person approached you and touched your right breast, what did you
do?
A: ________________________________.
12. Q: After being shocked for a while to what was done to you, what did you do next?
A: ________________________________.

13. Q: Were you able to finish answering the call of nature?

A: _________________________________________________

14. Q: While standing, what happened, if any?

A: _________________________________________________

15. Q: What happened next after AB pulled you towards the door of the comfort room?
A: ______________________________

16. Q: What, if any, did you do after AB touched and massed your breast?
A: _________________________________________________

17. Q: For how long did AB touched and massed your breast?
A: _________________________________

18. Q: Was this lascivious conduct of AB noticed by any one in the party?
A: ________________________

19. Q: What happened to the on going celebration?

A: _____________________________________________

20. Q: What did you do after that?

A: ___________________________________________

21. Q: Relative to this incident, do you recall having executed a sworn statement or an
affidavit?
A: ___________________________________________

22. Q: Showing you this document, what relation, if any, has this to do with the sworn
statement you executed in this case?
A:________________________

23. Q: This sworn statement consists of two pages, on page 2 at the bottom thereof, there is a
signature, who signed that?
A: ________________________

24. Q: Do you have a copy of the excerpt of the Police/Brgy. Blotter?

A: ____________________________________

25. Q: What legal step did you do after that?

A:__________________________________

26. Q: What happened to the confrontation in the barangay?

A: ______________________________________

27. Q: What document, if any, was issued to you by the barangay after conciliation between
you and AB failed?
A: ______________________________________

28. Q: The attached Sworn Statement marked as Exh A, Police/Barangay Blotter, and
Certification to file action (CFA), what relation do they have in relation to the documents
you earlier mentioned?
A: _________________________________________________
 That the herein affiant warrants that the copy of document or reproduction attached to
this Judicial Affidavit is a faithful reproduction of the original thereof.

IN WITNESS WHEREOF, affiant has hereunto affixed his/her signature on this ____
day of ___________, 2012 hereat San Jose Del Monte City, Bulacan.

Affiant

SUBSCRIBED AND SWORN BEFORE ME on the date and place above mentioned.

Prosecutor

ATT E STAT I O N

________________________, upon being duly sworn, deposes and states:

1. That he supervised the examination of the witness;

2. He faithfully recorded or caused to be recorded the questions he asked and the
corresponding answers that the witness gave; and
3. Neither he nor any other person then present or assisting him/her coached the witness
regarding the latters answer.

IN WITNESS WHEREOF, he affixed his/her signature on the date and place first written.

Prosecutor

SUBSCRIBED AND SWORN BEFORE ME on ___day of__________, 2012 hereat

the City of San Jose Del Monte, Bulacan.

Administering Officer