Slight Physical Injuries

Republic of the Philippines P hilippines 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 Was ther there e any any unus unusua uall inci incide dent nt that that occu occurr rred ed on (tim (time e and and plac place e of 

incident)?

 _______________  _______________________ _______________ ______________ ______________ ______________ _______________ _______________ ___________  ____   _______________  _______________________ _______________ ______________ ______________ ______________ _______________ _______________ ___________  ____ 

4. What was was that unusu unusual al incide incident nt that occur occurred? red?

 _______________  _______________________ _______________ ______________ ______________ ______________ _______________ _______________ ___________  ____   _______________  _______________________ _______________ ______________ ______________ ______________ _______________ _______________ ___________  ____   _______________  _______________________ _______________ ______________ ______________ ______________ _______________ _______________ ___________  ____ 

5.

Did you report the incident to t o 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