Republic of the Philippines

National Capital Judicial Regional

METROPOLITAN TRIAL COURT
Branch _______, Makati

PEOPLE OF THE PHILIPPINES,

Plaintiff,

-versus- Criminal Case No. ____________________

For: Violation of B.P. 22
________________________,
Accused,
x----------------------------------x

JUDICIAL AFFIDAVIT
of
_______________________

Witness: ______________

Examining Lawyer:
______________________
Assistant City Prosecutor
Office of the City Prosecutor
New Makati City Hall Building
Poblacion, Makati

Place of Examination:
Makati City

OFFER: The testimony of this witness is being offered to prove:

1) That he personally delivered a copy of the notice of dishonor with demand for payment
dated __________ to the accused at his given address located at ________________ on
_________________ and was personally received by the latter on _____________;

2) That the same notice of dishonor with demand for payment was also sent to the accused
via registered mail and was duly delivered and received at the residence of the latter on
__________ as evidenced by the registry return card;

3) That he will identify the notice of dishonor together with the registry receipt and registry
return card;

4) That he will also identify the affidavit of service he executed in connection with the
delivery and mailing of the notice of dishonor to the accused and such other relevant
matters.

I, _____________________, of legal age, ___________ and with residence address at

_______________________________, after having been duly sworn to in accordance with law,
hereby depose and say that all my allegations in this judicial affidavit are true and correct to the
best of my knowledge and that in answering the questions asked of me, I am fully conscious that
I do so under oath, and that I may face criminal liability for false testimony or perjury if found to
be lying in my testimony.

Q: What is your present occupation?

A: I am currently the messenger of _________________ with office located at
________________________.

Q: What are your duties and responsibilities?

A: As messenger, my duties and functions include, among others the filing and service of
pleadings, demand letters, and other documents.

Q: Are you familiar with the accused _____________?

A: Yes sir.

Q: Why are you familiar with the accused?

A: I am familiar with the accused because I was instructed to personally serve on him a copy of a
notice of dishonor with demand for payment dated ___________ on ______________.

Q: Mr. Witness if a copy of the notice of dishonor with demand for payment dated ___________
will be shown to you will you be able to identify it?
A: Yes sir.

Q: I am showing to you a notice of dishonor with demand for payment dated _____________.
What is the relation, if any, of this notice of dishonor to the notice of dishonor with demand for
payment you mentioned?
A: This is the same notice of dishonor with demand for payment which I personally delivered
and served to the accused on _____________. Your Honor, the notice of dishonor with demand
for payment dated __________ was already marked as Exhibit “___”

Q: Mr. Witness kindly tell to this Honorable Court how did you serve a copy of the notice of
dishonor to the accused?
A: Sir, on _________ I went to the residence address of the accused located at
________________. There I met the accused. Accordingly, I requested him to receive the notice
of dishonor to which he did by affixing his signature in the receiving copy.

Q: I am showing to you the receiving copy of the notice of dishonor. Kindly point to the
signature of the accused as appearing in the notice of dishonor.
A: That is the signature of the accused. (The witness pointed to the signature of the accused as
appearing on the _____________ of the notice of dishonor). Your Honor, may we request that
the signature of the accused as appearing in the notice of dishonor be marked as Exhibit “__”

Q: Why do you say that, that is the signature of the accused?

A: I personally saw her sign on the notice of dishonor and even indicated therein the date of her
receipt of the notice.

Q: Aside from delivering to the accused the notice of dishonor what else, if any, did you do with
respect to the notice of dishonor?
A: I also sent the notice of dishonor to the accused by registered mail.

Q: What is proof that you also sent a copy of the notice of dishonor to the accused by registered
mail?
A: The registry receipt sir.

Q: I am showing to you the registry receipt with no. _______, kindly tell us what relation, if any,
of this registry receipt to the registry receipt you mentioned?
A: This the registry receipt sir. Your Honor, may we request that the registry receipt with no.
________ be marked as Exhibit “___”

Q: Do you have any proof to show that the notice of dishonor you sent by registered mail to the
accused was indeed received by the latter?
A: Yes sir.

Q: What is your proof?

A: The registry return card sir.

Q: I am showing to you a registry card, kindly tell us what relation, if any, of this registry return
card to the registry return card you mentioned?
A: I executed an affidavit of service sir.
Q: If a copy of that affidavit service you executed will be shown to you will you be able to
recognize the same?
A: Yes sir.

Q: I am showing to you an affidavit of service consisting of ____ pages, kindly tel us what
relation, if any, of this affidavit of service to the affidavit of service you mentioned?
A: This is the same affidavit of service I have executed sir. Your Honor, may we request that the
affidavit of service be marked as Exhibit “__”

Q: On the ___ page of the affidavit of service there appears a signature on top of the name
__________________ whose signature is that?
A: That is my signature sir.

Q: Under your present oath do you still affirm and confirm the truthfulness and veracity of all
your allegations contained in your affidavit?
A: Yes sir. Your Honor, may we request that signature of ____________ be marked as Exhibit
“__”.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day November 2014
at Makati City, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this ___ day of November 2014 at Makati
City, affiant personally appeared and exhibited to me her _________________________.

Assistant City Prosecutor

ATTESTATION OF ASSISTING COUNSEL

I, ______________________, of legal age, married, and with office address located at

_____________________, after having been duly sworn to in accordance with law hereby
depose and say that:

1.) I have conducted and supervised the examination of affiant;

2.) I have faithfully recorded the questions I propounded to the affiant and the
corresponding answers of the latter,
3.) Neither I nor any other person then present coached the affiant regarding the latter’s
answers.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of November
2014 at Makati City, Philippines.

Assistant City Prosecutor

SUBSCRIBED AND SWORN to before me this ____ day of November 2014 at Makati
City.

Assistant City Prosecutor