COMPLAINT-AFFIDAVIT

I, _____________, Filipino, of legal age, (single / married / widow), and a resident of _____________,
Philippines, after being sworn to in accordance with law, depose and state:

That I know the person of __Respondent__, who is a resident of _____________, Philippines;

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 I have
extended to (him/her);

That the said check is drawn against the account of the said __Respondent__ at __Name of Bank__ with
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 for 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 said check is hereto attached as Annex "____";

As such, 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, __Respondent__ has unjustifiably 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 this _____________ at _____________,

Philippines.

COMPLAINANT

SUBSCRIBED AND SWORN to before me this _____________ at _____________.I hereby certify that I
have examined the Affiant and that I am fully satisfied that (he/she) has voluntarily executed and
understood the contents of (his/her) Complaint-Affidavit.

Administering Officer

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