Republic of the Philippines}City of xxx} s.s.COMPLAINT-AFFIDAVIT

I, NAME, of legal age, married, resident of address, after having been duly sworn in accordance with the law do hereby depose and say that:

1. (narration of facts)Affiant further sayeth naught. IN WITNESS WHEREOF, I hereunto affix my signature below, this 24th day of February 2016 in the City of xxx, Philippines.

_________________________________________

Affiant

Govt Issued ID

Valid Until

Date of Issue

Place of Issue

SUBSCRIBED AND SWORN to before me this _____________th day of ____________ 20___________ in the City of ________________________.

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