Republic of the Philippines

MUNICIPAL CIRCUIT TRIAL COURT

_______________, CEBU

PEOPLE OF THE PHILIPPINESPlaintiff, CRIM. CASE NO. ________

FOR: SLIGHT PHYSICAL INJURIES

-versus-

__________________________________________________________

Defendant, x - - - - - - - - - - - - - - -- - - - - - - - - - /

Republic of the Philippines)

Province of Cebu ) S.S.

JUDICIAL AFFIDAVIT

I, ______________________________, of legal age, residing at

________________________________________ after having duly sworn to in

accordance with law do hereby depose and state; that,

1. Where were you on (time and place of incident)?

______________________________________________________________________

______________________________________________________________________

2. What were you doing on that particular time and place?

______________________________________________________________________

______________________________________________________________________

3. Was there any unusual incident that occurred on (time and place of

incident)?

______________________________________________________________________

______________________________________________________________________

4. What was that unusual incident that occurred?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

5. Did you report the incident to the police?

______________________________________________________________________

______________________________________________________________________

6. Do you have a copy of the police report about the incident?

______________________________________________________________________

______________________________________________________________________

7. After the incident, did you seek medical intervention?

______________________________________________________________________

_____________________________________________________________________

8. Do you have a copy of your medical certificate?

______________________________________________________________________

______________________________________________________________________

9. Do you have grudges against the accused?

______________________________________________________________________

______________________________________________________________________

10.Were you forced to testify against the accused?

______________________________________________________________________

______________________________________________________________________

11.Will you be able to identify the accused inside this court room?

______________________________________________________________________

______________________________________________________________________

IN WITNESS WHEREOF, I hereunto affix my signature this _______ day of __________ 2012 Cebu City, Philippines.

____________________________ Affiant

SUBSCRIBED AND SWORN to me before this _____ day of __________ 2012 at __________, Cebu, Philippines.

____________________________ Officer in charge