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.
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.