Complaint-Affidavit for Filing of B.P.

22 Case)

COMPALINT-AFFIDAVIT

I, _________________, of legal age, Filipino, (single / married / widow), and a resident of

_______________, Philippines, after being sworn in accordance with law, hereby depose and state:

1. That I know the person Respondent , who is a resident ______________, Philippines;

2. That sometime in the morning of date of issue , at place of issue , Philippine, the
said Respondent , issued in my favor a Name of Bank , Check No. _____________ in the
amount of P ____________ as supposed payment for the loan accommodation of P
____________, which I have extended to (him/her);

3. That the said check is drawn against the account of the said Respondent at Name of
Bank with Account No. _____________;

4. That at the time the said Respondent issued the delivered the said check to me, (he/she) made
the assurance and representation that the said check is a good check and would be covered by
sufficient funds when presented for payment;

5. However, when the above-mentioned check was deposited, the same was dishonored and
returned by the bank on the ground that the same was drawn against a “CLOSED ACCOUNT.”
A true and faithful machine reproduction of the said check is hereto attached as Annex “_____”;

6. As such I immediately notified said Respondent of the dishonor and return of the said check
and demanded from (him/her) that (he/she) make good the said check within ______________
(_____) days from receipt thereof. A true and faithful machine reproduction of my demand letter
to (him/her) is hereto attached as Annex “_____”;

7. When said Respondent failed to heed my demands, I endorsed the said check to my legal
counsel who immediately sent a formal demand letter through registered mail with return card on
_____________, which was received by the said Respondent on _____________. As of date
however, Respondent has unjustifiably ignored all these demands to pay the said account
and/or to redeem the said returned check. A true and faithful machine reproduction of my
demand letter to (him/he) is hereto attached as Annex “______”;

8. I am therefore executing this Complaint-Affidavit in support of the charges for Violation

of Batas Pambansa Bilang 22 against the said Respondent , who may be served with
subpoena and other processes of this Honorable Office at (his/her) last known address at
______________, Philippines;

IN WITNESS WHEREOF, I have hereunto set my hands 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/she) has voluntarily executed
and understood the contents of (his/her) Complaint-Affidavit.