Slight Physical Injuries

Republic of the Philippines MUNICIPAL CIRCUIT TRIAL COURT _______________, CEBU PEOPLE OF THE PHILIPPINES Plaintiff,

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