Republic of the Philippines

MUNICIPAL TRIAL COURTS IN CITIES

10th Judicial Region
Branch 6
Cagayan de Oro City

PEOPLE OF THE PHILIPPINES, Crim. Case Nos.

Plaintiff, ________________________

-versus- For:

__________________________, Violation of B.P. Blg. 22 (8

Accused. counts)
X--------------------------------------------//

JUDICIAL AFFIDAVIT
For _______________________
(in lieu of direct testimony)

I, ________________________, of legal age, Filipino and a resident of

___________________________________, Philippines, after having been
duly sworn to in accordance with law do hereby depose and state:

PRELIMINARY STATEMENT

That in accordance with A.M. No. 12-5-8-SC, which prescribes the use
of judicial affidavits to serve as the direct examination testimony of the
witness, on the basis of which the adverse party may conduct their cross-
examination on such a witness, I hereby execute this judicial affidavit in a
question and answer format;

That conformably with section 3(b) of the said A.M. No. 12-8-8-SC, I
also state that it was _______________________, private prosecutor for the
plaintiff, who conducted the examination of the undersigned affiant at
__________________________;

That conformably also with section 3(c) thereof, I hereby state under
the pain of perjury that in answering the questions asked of me, as
appearing herein below, I am fully conscious that I did so under oath, and
that I may face criminal liabilities for false testimony or perjury;

QUESTION AND ANSWER

1. Q: What is your complete name?

A:

2. Q: What is your occupation?

A:

3. Q: Are you the same ________________________ who

executed the Affidavit of Service attached in the
complaint of ________________ against _____________ for
violation of Batas Pambansa Blg. 22?
A: Yes, I am.

4. Q: I am showing you an original copy of the affidavit of

service you have just mentioned. Kindly examine if this is
the same affidavit you were referring to?
A: Yes, that is the affidavit that I mentioned earlier. I was the
one who executed the same.

5. Q: Why did you execute the said affidavit?

 A: Because I was the one who personally mailed the notice of
dishonor and demand letter through registered mail and
private courier.

6. Q: When was this notice of dishonor and demand letter

mailed?
A: I mailed the said document by registered mail with registry
return card on _________________. On the following day,
___________________, I was also the one who mailed the
document through LBC.

7. Q: I am showing you an original copy of the Registry Receipt

no. ___________________ from the Philippine Postal
Corporation and LBC Receipt with tracking no.
____________________that you have just mentioned.
Kindly examine if these are the same receipts you were
referring to?
A: Yes. That is the Registry Receipt and LBC receipt I am
referring to.

8. Q: To whom is the said document addressed?

A: It is addressed to ___________________

9. Q: What is the address indicated in the said document?

A: The address specified is ________________
No further questions.

Affiant further sayeth naught.

IN WITNESS WHEREOF, I have hereunto set my hand this

__________________, at Cagayan de Oro City, Philippines.

_________________________
Affiant

SUBSCRIBED AND SWORN to before me this ___________, at

Cagayan de Oro City, Philippines. Affiant _____________________
exhibited to me his ____________________.

Witness my hand and seal.

Doc. No. ____:

Page No.____:
Book No.____:
Series of 2018.