Republic of the Philippines )

Province of Panay )S.S.

COMPLAINT-AFFIDAVIT

I, _________, of legal age, Filipino citizen, single, a

resident of Brgy.___________, after having been duly
sworn to in accordance with law, do hereby depose and
say that:

1. I personally know ___________ being also a

resident of Barangay
Poblacion,__________________.

2. That sometime on September 2016, while me

and my sister-in-law were watching TV inside
our house I heard ___________ calling my
name in a loud voice and urging me to went out
of our house.

3. Curious of what ___________was up to I went

outside our house along with my sister-in-law,
thereupon to my surprise pointed her fingers on
my face almost poking me and intentionally
shouted “Puta! Burikat! Pokpok ka kay ikaw
una nabuntisan”

4. I was speechless for a second then I realized

that our neighbours,
___________________________, also came
out of their houses.

5.Feeling ashamed of what was happening I

immediately went inside our house but then
Mary kept on shouting “Burikat! Pokpok ka
Burikat ka Joyce”.
 6. The statements uttered by _________on that
day publicly and clearly prompted not by sense
of moral duty but by personal ill-will, spite and
malice with the object of destroying my
reputation and discrediting and ridiculing me as
an individual before the bar of public opinion and
contempt.

7. The ill-effects of the malicious utterances are

shown by the negative responses that I have
received from my neighbours, expressing belief
in Mary’s baseless allegations as shameful,
heinous and unequivocally barbaric all to my
damage and prejudice.

8. By reason of the foregoing, I suffered sleepless

nights, wounded feelings, and moral and social
embarrassment.

9. I am executing this affidavit to attest the truth

of the foregoing statements and for the purpose
of filing the necessary criminal and/or civil
action against

IN WITNESS WHEREOF, I have hereunto set my

hand this ___ day of ____________ at Panay City,
Philippines.

Complainant

SUBSCRIBED AND SWORN to before me

this_______day ___________________ at, Philippines
by the affiant whom I personally examined and I am
satisfied that she voluntarily executed and understood
her said affidavit.