Republic of the Philippines )

City of ) S.S.

AFFIDAVIT/SWORN STATEMENT
in support of a Small Claims Complaint

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

___________________________, under oath state THAT –

1. I am executing this Affidavit to attest to the truth of

____________________ liability for not returning the security deposit in
the amount of __________ paid to it under the contract of lease;

2. I am the Resident Agent of ______________ and its

authorized representative to the lease contract entered into by and
_______________, represented by its Vice-President, ________ and
__________;

3. ______________________, as the lessor and

_____________________ _______, as the lessee, entered into a lease
contract for a period of 2 years, beginning on November 5, 2016 and
ending on November 4, 2018. A copy of the said contract of lease is hereto
attached;

4. During the effectivity of the contract, and while

_____________________ was occupying the premises, it made several
requests to the lessor to fix the airconditiong system in the leased unit
since the lessee cannot fix the same without having to employ a contractor
approved and acceptable to the lessor;

5. On ____________, however, _____________________ was

constrained to pre-terminate the contract and vacate the property subject
of the lease due to ______________’s inability to fix the airconditioning
system, which has disrupted the operations of the former, despite repeated
request made upon the latter;

6. _____________________ vacated the leased premises and left

it in a tenantable condition, without any unsettled accounts;

7. _____________________ issued postdated checks covering

the monthly rentals for the period of 2 years, in compliance to the covenant
under the lease contract as well as advance rentals equivalent to two (2)
months rental and security deposit equivalent to two (2) months rental;

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 8. Thus, in sum, _____________________ has caused the
following payments to ______ as evidenced by various Acknowledgment
Receipts, to wit:

Date Amount Received by

TOTAL

9. _____________________ paid a total of

____________________ to _______ equivalent to two (2) months rental
and two (2) months security deposit;

10. _____________________ made a final demand upon

KEPWEALTH to return the amount of ____________, representing the
security deposit, which was received by the latter’s representative on
______________. A copy of the final demand letter is hereto attached;

11. _________ has failed to return the said amount representing

the security deposit up to this date, despite demand to return the same.
Hence, _____________________ initiated a Small Claims Case against
________;

12. I execute this Affidavit to attest to the foregoing statements

and as evidence in support of the claim against _________. Also attached
are the following documentary evidence in support of this claim:

a) (date) Acknowledgment Receipt

b) (date) Acknowledgment Receipt
c) (date) Acknowledgment Receipt
d) (date) Acknowledgment Receipt
e) (date) Acknowledgment Receipt
f) Demand Letter

13. After due notice and hearing, _____________________ seeks

judgment from this Honorable Court ordering _______ a) to return the
money paid to it, b) to pay damages, and c) to pay for Attorney’s Fees and
costs.

Affiant further sayeth naught.

IN WITNESS WHEREOF, I have hereunto set my hand this ____

_____________ 2019, _____, Philippines .

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 ___________________
Affiant

ID No. ________________________

SUBSCRIBED AND SWORN to before me this _______________

2019, affiant exhibited to me her above-cited Competent Proof of Identity.

Doc No. __
Page No. __
Book No. __
Series of 2019