Republic of the Philippines )

Province of Sorsogon ) Ss
City of Sorsogon )

COMPLAINT AFFIDAVIT
I, Mr. Jose Alamer, Filipino Citizen, 35 years old, married to Mrs Josefina Alamer
(deceased), and a resident of Abuyog, Sorsogon City hereby depose that:

1. That Juan dela Cruz is my childhood friend.

2. That we remained friends and even best of friends
3. That Juan dela Cruz is the godfather of my daughter.
4. That I am a godfather of his son and daughter.
5. That on 25 August 2020 I came from a derby and won a considerable
amount.
6. That sometime on 25 August 2020, Juan dela Cruz was waiting for me in
dire strait at my residence in Abuyog Sorsogon City, took chance to borrow
ONE HUNDRED THOUSAND PESOS ( P100,000.00).
7. That Juan dela Cruz narrated the ordeal suffered by her daughter as the
reason for borrowing such amount.
8. That I being a good friend did not hesitate to lend the amount in
consideration.
9. That because of the emergency circumstance I forgot to execute a receipt
to document Juan dela Cruz received the money he borrowed.
10. That on his way out of the garage he shouted in sorsoganon dialect “ibalik
ko lang padi after one month…promise…darhon ko nguna si ihada mo sa
ospital”
11. That my “cristo” placer of bet witnessed what transpired on that specific
time of 25 August 2020. (His statement is attached as ANNEX A.)
12. That the handlers of my fighting cocks also witnessed the same. (Their
statements are attached as ANNEX B and C respectively)
13. That ANNEX D is a copy of the Medical Certificate of Angelika dela Cruz,
daughter of Mr. Juan dela Cruz.
14. That ANNEX E is the copy of the X-Ray result of Angelika dela Cruz.
15. That during this execution of complaint Juan dela Cruz have not yet settled
his obligation despite of the demand letter issued to him.
16. That I am executing this complaint for SMALL CLAIMS under OCA
Circular No. 45-2019, effective 01 April 2019.

It is hereby prayed, to compel, oblige,mandate Juan dela Cruz to pay the amount of
One Hundred Thousand Pesos Only (P100,000.00) to Jose Alamer.
IN WITNESS WHEREOF, I have hereunto affixed my signature 6th day of October 2020
at Seabreeze Homes Cabid-an Sorsogon City, Province of Sorsogon

JOSE ALAMER
COMPLAINANT / AFFIANT

SUBSCRIBED and SWORN to before me this 6th day of October 2020 at Seabreeze
Homes Cabid-an Sorsogon City, Province of Sorsogon. I hereby certify that I have
personally examined the above-named affiant and that I am satisfied that the foregoing
statements were given by him voluntarily and of his own free will.

Doc No.__________: Atty. Beauty Contis

Page No._________: Notary Public
Book No._________: PTR No.7654321, Sorsogon City, 12/31/2020
Series of 2020 IBP OR No.123456, Sorsogon City, 12/31/2020
Attorney’s Roll No. 09876
MCLE Compliance Certificate No. V-67890 12/31/2020
 VERIFICATION/CERTIFICATION OF NON-FORUM SHOPPING

I, Jose Alamer, Compalainant in the above-mentioned affidavit, Filipino,of legal age,

married, after having been sworn, in accordance with law, hereby depose and state that:

1. I am the complainant in the above-mentioned complaint;

2. I read and understood the contents hereof of the complaint for Review, and the
facts herein alleged are true and correct of my knowlledge and based on available
verifiable records
3. I hereto have not commenced any other action or proceeding or any claim, or filed
any claim, involving the same issues raised in the above-mentioned complaint, in
this Honorable Supreme Court, in the Court of Appeals, nor the different Divisions
thereof, nor in any other court or tribunal or agency and to the best of my
knowledge, no such other action or claim is pending therein
4. I hereby undertake to notify this Honorable Court of such fact within 5 days from
receipt of such knwoledge, should I come to learn that the same or similar action or
claim has been filed or pending in the Supreme Court, Court of Appeals, the
different Divisions therof, or any other court or tribunal or agency;
5. I am executing this sworn statement in compliance with Section 5, Rule 7 of the
1997 Rules of Court

JOSE ALAMER
AFFIANT

SUBSCRIBED AND SWORN TO before me this 6th day of Ctober 2020 at

Seabreeze Homes Cabid-an Sorsogon City, Philippines, affiant exhibiting to me his
Driver’s Licence with DL No V-1234567890 issued by the Land Transportation Office as a
competent evidence of his identity and he personally acknowledge to me that the
foregoing “Complaint”is his free and voluntary act and deed.

Doc No.__________: Atty. Beauty Contis

Page No._________: Notary Public
Book No._________: PTR No.7654321, Sorsogon City, 12/31/2020
Series of 2020 IBP OR No.123456, Sorsogon City, 12/31/2020
Attorney’s Roll No. 09876
MCLE Compliance Certificate No. V-67890 12/31/2020
ANNEX A

SWORN STATEMENT

Ako si Lucas Evangelista, Pilipino, 40 anyos na taga buhatan Sorsogon City, my agom.
Asin sarong cristo sa bulangan nagiistorya:
1. Na kan petsa 25 kan agosto taon 2020 iniba ako kan sakong pustadores na si
Jose Alamer sa saindang harong sa Abuyog Sorsogon City para mag inom nin
huli ta medyo sinwerte sa bulang, gumana nin mas o menos P200,000.00.
2. Na kan pag abot sa saindang harong naabotan mi ang sarong lalaki na
problemado ang itsura tulos na nag sabi “padi pautanga daw ki P100,000”
3. Na hinapot su lalaki “ano ta mautang ka?mejo dakulang kantidad baga an”
4. Na nagsimbag si lalaki “iyo padi ta si ihada mo nahulog sa hagdan sa
eskwelahan tinulak daw kan kaklase .dadarhon ko sa hospital ta bari ang siko”
5. Na daeng duwa duwa inabot ni Sir Jose su kwarta.
6. Na tulos uminali ang lalaki
7. Na pagabot sa gate nag kurahaw su lalaki “ibalik ko man sana tulos..mga
sarong bulan lang padi bayadan taka na”

IN WITNESS WHEREOF, I have hereunto affixed my signature 6th day of October 2020
at Seabreeze Homes Cabid-an Sorsogon City, Province of Sorsogon

LUCAS C. EVANGELISTA
AFFIANT

SUBSCRIBED and SWORN to before me this 6th day of October 2020 at Seabreeze
Homes Cabid-an Sorsogon City, Province of Sorsogon. I hereby certify that I have
personally examined the above-named affiant and that I am satisfied that the foregoing
statements were given by him voluntarily and of his own free will.

Doc No.__________: Atty. Beauty Contis

Page No._________: Notary Public
Book No._________: PTR No.7654321, Sorsogon City, 12/31/2020
Series of 2020 IBP OR No.123456, Sorsogon City, 12/31/2020
Attorney’s Roll No. 09876
MCLE Compliance Certificate No. V-67890 12/31/2020
ANNEX B

SWORN STATEMENT

Ako si Mateo dela Pueblo, Pilipino, 25 anyos, taga Bulan Sorsogon City, soltero asin
nagtatrabaho bilang taga alaga kan mga manok ni Jose Alamer nagiistorya kung ano ang
nahiling ko asin nadangog sa pag istoryahan ni Sir Jose tapos padihon nyang si Juan:
1. 1.Na kan hapon kan petsa 25 kan Agosto 2020, mantang ako
nagpapakaon kan mga manok nag abot si Juan asin tighanap ang
sakong boss na si Jose
2. Na ako nag simbag “wara pa si boss nagbulang.pero nagtext na pauli na
sinda tigpapa katay ngani sui bang manok ta mairinom ta gana daw sya
bulang”
3. Na si Jose suminabi “salamat kung gana si padi,baka makautang lamang
ako ta dadarhon ko su aki sa ospital”
4. Na tulos pag abot ni boss Jose tulos sinabat ni Juan direcho sabi “padi
maray sana ta garu gana ka.mautang daw ako ta si ihada mo na
diskwido sa eskwelahan nahulog sa hagdan tinulak daa kan kaklase”
5. Na tulos inabot ni boss Jose ang kwarta.
6. Na tulos huminali si Juan paka risibi kan kwarta.

IN WITNESS WHEREOF, I have hereunto affixed my signature 6th day of October 2020
at Seabreeze Homes Cabid-an Sorsogon City, Province of Sorsogon

MATEO B.DELA PUEBLO

AFFIANT

SUBSCRIBED and SWORN to before me this 6th day of October 2020 at Seabreeze
Homes Cabid-an Sorsogon City, Province of Sorsogon. I hereby certify that I have
personally examined the above-named affiant and that I am satisfied that the foregoing
statements were given by him voluntarily and of his own free will.

Doc No.__________: Atty. Beauty Contis

Page No._________: Notary Public
Book No._________: PTR No.7654321, Sorsogon City, 12/31/2020
Series of 2020 IBP OR No.123456, Sorsogon City, 12/31/2020
Attorney’s Roll No. 09876
MCLE Compliance Certificate No. V-67890 12/31/2020
ANNEX C

SWORN STATEMENT

Ako si Marcus Torres, Pilipino, 29 anyos, taga Casiguran, Sorsogon, my agom,

nagtatrabaho bilang taga alaga kan mga manok ni Jose Alamer mina istorya kan sakong
mga nadangog kan hapon kan petsa 25 Agosto 2020
1. Na kan hapon kan petsa 25 kan Agosto ngunyan na taon my
kaistoryahan si boss na lalaki
2. Na kan paghali kan lalaki nagsabi “ibalik ko man sana tulos saimo
padi”

IN WITNESS WHEREOF, I have hereunto affixed my signature 6th day of October 2020
at Seabreeze Homes Cabid-an Sorsogon City, Province of Sorsogon

MARCUS G. TORRES
AFFIANT

SUBSCRIBED and SWORN to before me this 6th day of October 2020 at Seabreeze
Homes Cabid-an Sorsogon City, Province of Sorsogon. I hereby certify that I have
personally examined the above-named affiant and that I am satisfied that the foregoing
statements were given by him voluntarily and of his own free will.

Doc No.__________: Atty. Beauty Contis

Page No._________: Notary Public
Book No._________: PTR No.7654321, Sorsogon City, 12/31/2020
Series of 2020 IBP OR No.123456, Sorsogon City, 12/31/2020
Attorney’s Roll No. 09876
MCLE Compliance Certificate No. V-67890 12/31/2020
ANNEX D

30 August 2020

MEDICAL CERTIFICATE
To Whom It May Concern,

Miss Angelika dela Cruz was brought to my attention and after proper examination
was diagnosed to have suffered a Supracondylar fracture on her left elbow. I together with
the team of doctors and nurses performed the orthopedic surgery by realigning the bone
and inserted wires – about the diameter of a pencil lead into the bone and across the
fracture site, this approach provides and helps maintain proper alignment while protecting
the growth plate. The wires extended through the skin and covered with cast.
The patient is advised for a follow check up after four weeks. We may recommend
a physical therapy upon further examination on the healing process and elbow motion.

Jeremy LLanto MD
Licence number 12345
ORTHOPEDIC SURGEON

Doc No.__________: Atty. Beauty Contis

Page No._________: Notary Public
Book No._________: PTR No.7654321, Sorsogon City, 12/31/2020
Series of 2020 IBP OR No.123456, Sorsogon City, 12/31/2020
 Attorney’s Roll No. 09876
MCLE Compliance Certificate No. V-67890 12/31/2020