REPUBLIC OF THE PHILIPPINES )

) S.S.

COMPLAINT-AFFIDAVIT

I, _____________________________, of legal age, Filipino Citizen and with office

address at ______________________________City, after having duly sworn to in
accordance with the law hereby depose and say:

1. I am the the authorized representative of ____________________________, a

corporation duly organized and existing under Philippine laws, with
principal office address at_______________________. Copy of the Secretary
Certificate is hereto attached as Annex “A”;

2. As such my duties and responsibilities included among others, monitoring

of payments of the borrowers of the corporation, filing of the necessary
complaint against the delinquent borrowers and testifying in court in behalf
of the corporation;

3. On ________________, MS. __________________ of legal age, Filipino and

resident at ________________________ in consideration of the loan she
obtained issued postdated check in favor of the said corporation.

4. The copy of the application form is attached as Annex “B”. The copies of
the promissory note including disclosure statement of loan are hereto
attached as Annexes “C / C-1”. and the copy of the check including the
dorsal side are hereto attached as Annexes “D / D-1”;

5. When the said check was deposited in__________________________Branch,

the same was returned and dishonored by the drawee -
___________________________ for the reason “ACCOUNT CLOSED”;

6. A demand letter was sent to Ms. Ma. Elena R. Ramirez for her to make
good of the said dishonored check. Copy of the demand letter dated
______________ is attached as Annex “E”. The copy of affidavit of service is
attached as Annex “F”;

7. Despite the demand, Ms. _________________ failed to clear the said check
and refused to pay and settle her obligation amounting to Php286,981.00
as of _______________ to the prejudice of the corporation;

8. That I am executing this affidavit in order to attest to the truthfulness of

the matter stated above and for the purpose of filing a criminal complaint
for violation of ____________________________ against Ms. Ma. Elena R.
Ramirez.
AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of

________,______ at ___________ City.

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this day of ________, _____. 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 affidavit.

Asst. City Prosecutor