REPUBLIC OF THE PHILIPPINES )

CITY OF QUEZON ) s.s.

AFFIDAVIT

I, (AFFIANT), Filipino, of legal age, married, and residing at

(ADDRESS), after having sworn in accordance with the law, do hereby
depose and states that:

1. I am the father of (AFFIANT), one of the accused in a criminal case

Nos. ________ for ______________;

2. On (DATE), due to chest pain and difficulty in breathing, I asked my

son, (AFFIANT RELATIVES) to take me at (HOSPITAL);

3. On even date, my son accompanied me at (HOSPITAL), however,

upon arrival thereat, we were informed that (PHYSICIAN) was not
on duty as she was attending a Convention;

4. Because (PHYSICIAN) was not on duty, I was not issued any

Medical Certificate or any prescription, and that it took me some time
to rest before I could leave the premises of (HOSPITAL);

5. Thereafter, I was informed that my son arrived late on his scheduled

hearing because I asked him to accompany me at (HOSPITAL);

6. I was not aware on that day that my son had a scheduled hearing;

7. That I am executing this Affidavit to attest to the truth of the

foregoing facts, and for all legal purpose it may serve.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS HEREOF, I have hereunto affixed my signature this

(DATE) in Quezon City.

__________________________
(AFFIANT)
Affiant

SUBSCRIBED AND SWORN before me in Quezon City, this

(DATE), affiant personally appeared before me and exhibited to me his ID
with No. _________ bearing his signature and photograph as competent
proof of his identity.

NOTARY PUBLIC
Administering Officer