COMPLAINT-AFFIDAVIT

I, ___________________________, of legal age, married, Filipino

and a resident of
__________________________________________________, Metro Manila,
after being sworn to in accordance with law, depose and state that:

1. Sometime around 4:00p.m. in the afternoon of June 12, 2020

in Quezon City, specifically along ________________________,
________________________________ to be hereinafter referred to
as the Accused, who is a resident of
__________________________________________ being then the
driver of a maroon colored Isuzu Crosswind with plate number
__________________, did then and there willfully, unlawfully and
feloniously drive, manage and operate the same in a reckless,
careless, negligent and imprudent manner, without regard to
traffic laws, rules and regulations, and without taking the
necessary care and precaution to avoid damage to property,
causing by such negligence, carelessness and imprudence the
said vehicle to collide violently and head on with Toyota Hi-
Lux bearing plate number _______________ driven by my driver,
_____________________________ thereby causing damage to
latter vehicle which would require repair estimated at
P500,000.00.

A copy of the Toyota Hi Lux Original Receipt and Certificate of

Registration is hereby attached as ANNEX ”A” and “A-1”,
respectively. A copy of the damages incurred by my vehicle are
hereby attached as ANNEX “B”, “B-1”, and “B-2”, and made
an integral; part hereof. A copy of the repair quotation is
hereby attached as ANNEX ”C”;
2. Due to the ongoing COVid-19 pandemic and my driver living
in my residence as a stay-in driver, I secured the services of
legal counsel in order for the him to execute his written
statement under oath regarding the accident that took place
on June 12, 2020, instead of going to the the Balintawak
Traffic Management Sector 1. As contained in said affidavit
and going back to what had transpired, I was riding in the
passenger seat on our way home when nearing Calamba
Street, we noticed the vehicle driven by the Accused crossed
over to our lane at a great speed which made my driver swerve
further to the right to avoid a head-on collision.

A copy of the Affidavit of Accident is hereby attached as

ANNEX “D” and made an integral part of this complaint.;

3. The impact of collision threw my vehicle to the curb, almost

turning it turtle, rendering both doors on the left hand side
stuck. Digital copies of the Closed Circuit TeleVision (CCTV) of
_____________________ the onboard dash cam video, and
screenshot of the vehicle of the accused seconds before impact
are hereby attached as ANNEX “E”, “E-1” and “E-2”, saved
respectively in the Universal Serial Bus (USB) drive enclosed
with this complaint-affidavit and made an integral part hereof;

4. Therefore, the acts of the Accused of sudden acceleration,

wrongful veering that resulted to counter-flowing, and the
clear failure to stop her car clearly establish the reckless and
imprudent manner of driving her vehicle. Indeed, Accused,
being a licensed driver, should have ensured that driving in
the right lane and maintaining a reasonable speed which she
 failed to do so, are expected of in an ordinary driving scenario
as shown in the video files of the incident;
5. On June 20, 2020, I have secured services of legal counsel to
prepare and serve upon the Accused a demand letter on her
registered address. The same was received by
____________________, the older brother of the Accused.

A copy of the said demand letter is hereby attached as ANNEX

“E” and made an integral part hereof;

6. On June 22, 2020, my legal counsel received an SMS message

from the cellphone number of the Accused asking for a phone
call and it was the father of the Accused (Mr. Ong) who tried to
talk the matter out, but ultimately ended in disagreement for
reasons totally unrelated to the complaint for reckless
imprudence;

7. I am therefore executing this Complaint-Affidavit in support of

the charges for Reckless Imprudence Resulting in Damage to
Property against the said Accused.

IN WITNESS WHEREOF, I have hereunto set my hand 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 has voluntarily executed and
understood the contents of his Complaint-Affidavit.
REPUBLIC OF THE PHILIPPINES )
QUEZON CITY ) S.S.

SINUMPAANG SALAYSAY
NG AKSIDENTE

Ako ay si ________________________________, may wastong

gulang, Pilipino at naninirahan sa
_________________________________________ pagkatapos manumpa ng
ayon sa batas ay malayang nagsasabi at nagsasalaysay ng buong
katotohanan ng mga sumusunod:

1. Ako ay kasulukuyang namamasukan kay

Ginoong _______________________________ bilang
tagapagmaneho at ako ay kasulukuyang din
nakikitira sa _________________________________,
Metro Manila dahil sa paggunita sa palatuntunan ng
lockdown guidelines laban sa COVId-19 sa Lungsod
ng Quezon City;

2. Noong Hunyo 12, 2020, humigit kumulang alas

kwatro ng hapon (4:00 pm) pinagmamaneho ko ang
aking maypagawa upang umuwi sa kanilang
tahanan. Nasa kahabaan na kami ng Santo
Domingo Street patungong Quezon Ave nang
magtaka ako sa isang kulay maroon na Isuzu
Crosswind na sinusundan ng makapal na usok
buhat biglang pagtapak sa silinyador na lumihis
papunta sa parte ng kalye kung saan kami
nakatoon;
3. Pinapatakbo ko ang pinagmamaneho kong
sasakyan na pagmamay-ari ng akin maypagawa sa
bilis na mahigi’t kumulang tatlumpong kilometro
kada oras (30KpH) at sa distansyang isang daan o
isang daan at limampung metro (100-150 meters)
mula sa maroon na Isuzu Crosswind, wala akong
ibang paraan kundi ikabig ang manibela papuntang
kanan upang maiwasan ang rumaragasang
sasakyan;

4. Kahit sa bilis ng aking reaksyon, natamaan pa

din ang kaliwang bahagi ng aking minamanehong
sasakyan at ang pwersa ng pagsalpok ay muntik na
kaming mataob sa gutter ng kanang bahagi ng
Santo Domingo Street;

5. Nang tumigil na ang sasakyan namin,

sinubukan kong bumaba ngunit hindi mabuksan
ang pinto ko buhat ng natamong pinsala mula sa
pagkabangga. Sa panahong iyon, tumatawag na ng
rescue ang aking maypagawa;

6. Nang dumating ang rescue team, bumaba ako,

ang aking maypagawa at ang kasama naming si
__________ sa mga pinto ng kanag parte ng
sasakyang aking minamaneho. Doon ko lamang
nakita ang lawak ng pinsala ng pagkasalpok sa
amin ng maroon na Isuzu Crosswind na mayroong
plate number _______________, at;
 7. Lahat ng pangyayaring ito ay navideohan ng
dashcam ng aking maypagawa at ng CCTV ng
Barangay ______________________ na matatagpuan
malapit sa Calamba Street kanto ng Santo Domingo
Street.

Lumagda at nanumpa sa aking harapan ngayong ika-

___________ ng _____________________ 2020 dito sa Quezon City at
ipinakita sa akin ang kanyang DRIVER’S LICENSE
___________________ na ibinigay noong ika-_______ ng
____________________ _____ sa _________________________________.