Republic 

of the Philippines )
Province of Palawan )S.S.
City/Municipality of Puerto Princesa )

COMPLAINT-AFFIDAVIT
I, ___________________, Filipino, of legal age, (single/married/widow/), and resident of
_________, Phillipines, when being sworn to in accordance with law, depose and state;
That I know the person of _____________________________ respondent _______________,
who is resident of _________________.
That sometime in the morning of ________________ date of issue______, at
__________________ place of issue _______________, Philippines, 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 Account No.
_________;
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 the payment;
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 and check is hereto attached as Annex
“_________”;
As much, 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 “_________”
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, 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/her) is hereto attached as Annex
“_________”
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 hand on this __th day of ____________,

2022 at Puerto Princesa City, Philippines
____________________
Affiant
SSS ID No. _____________
SUBSCRIBED AND SWORN to before me this ________________ at ______________, I
hereby certify that I have examined the Affiant and that I am fully satisfied that (his/her) has
voluntarily executed and understood the contents of (his/her) Complaint Affidavit.

Administering Officer