Republic of the Philippines)

Province of) S.S.

Municipality of )

AFFIDAVIT

I, JUAN DELA CRUZ, 21 years old, single, presently residing in Barangay 2, , after
having been sworn to an oath in accordance with law hereby depose and say THAT:

1. I am standing as complainant against XXX XXX, 46 years old, meat butcher,

resident of Barangay 1, Dolores, Eastern Samar, on the following averments:

2. On June 20, 1918 at around 12:30 in the morning, my brother, XXX, was
stabbed in the back by XXX along the corner of San Carlos Street and national
highway in Barangay 4, xxxx;

3. As consequence thereof, my brother, XXX, was brought to SSS Hospital, for

treatment, but subsequently brought to Saudi Provincial Hospital for a more
rigorous medical attention arising from the stab wound he sustained from the
incident. A copy of SSS Hospital Referral Form hereto attached and made an
integral part hereof;

4. I am executing this affidavit to attest the veracity of the foregoing statements

and to support in filing a criminal case of FRUSTRATED HOMICIDE (Article
250 of the Revised Penal Code) against AAA AAA before the Office of the
Assistant P;

IN TRUTH WHEREOF, I will affix my signature below this __ day of April 2018 in
______________, , Philippines.

XXX XXX XXX

Affiant

SUBSCRIBED AND SWORN to before me this ___ day of April 2018 in

_______________, SSS SSS and I hereby certify that I personally examined the affiant
and I am satisfied that he fully understands the contents of his affidavit and that he
voluntarily executed the same.