You are on page 1of 4

Republic of the Philippines

Province of Laguna

CITY/MUNICIPALITY OF SANTA CRUZ


Barangay Bagumbayan

OFFICE OF THE LUPONG TAGAPAMAYAPA

___________________ Barangay Case No. __012___________


___________________ For: Slight Physical Injuries__________
Complainant/s

____Derek Ramsay_______________

— against —

____John Lloyd Cruz______________

Respondent/s

CERTIFICATION TO FILE ACTION

THIS IS TO CERTIFY THAT:

1. There has been a personal confrontation between the parties before the Punong
Barangay but mediation failed;
2. The Pangkat ng Tagapagkasundo was constituted but the personal confrontation before
the Pangkat likewise did not result into a settlement; and
3. Therefore, the corresponding complaint for the dispute may now be filed in
court/government office.

This __18th___day of___February__, 2019.

________________________

Pangkat Secretary

Attested by:

___________________________

Pangkat Chairman
REPUBLIC OF THE PHILIPPINES )
Province of Laguna )
Municipality of Santa Cruz ) S.S.

COMPLAINT-AFFIDAVIT

I, Derek Ramsay, 27 years old, single, and a resident of Block 10,


Lot 1, Minorka Ville Subdivision, Brgy. Bagumbayan, Santa Cruz, Laguna
after having been duly sworn to in accordance with law, hereby depose and
state THAT:

1. Last February 14, 2019, on or about 9:00 A.M., while I was


heading home from the grocery store, my neighbor John Lloyd
Cruz, a resident of Block 10, Lot 10, Minorka Ville Subdivision,
Brgy. Bagumbayan, Santa Cruz, Laguna offered me shot a glass
of the liquor (Matador) they are drinking, but I refused;

2. Respondent, continually offered me saying, “Isang shot lang


pare!” but I refused again;

3. Respondent got irritated and he suddenly punched my face twice


which made me fall down on the ground;

4. He was about to punch me again but his companion Vhong and


Billy stopped him;

5. On the same day, I went to Holy Family Hospital to have an


examination of my swollen face and the injuries I sustained, and
the doctor recommended for a healing and rest period of nine (9)
days. Copy of the Medical Certificate is attached as “Annex A”
hereof;

6. Also, as a consequence of the swelling of my face I was not able


to report for work for seven (3) days;

7. On February 18, 2019, I filed a complaint before the barangay,


and after several hearings, no amicable settlement was reached
between the parties as evidence the Certificate to File Action
which is hereto attached as “Annex B”.

8. I am therefore executing this affidavit freely and voluntarily to


attest the truth of the foregoing statements and for the purpose of
charging the respondent John Lloyd Cruz for the crime of Slight
Physical Injuries penalized under Article 266 of the Revised Penal
Code.

IN WITNESS HEREOF, I hereunto set my hand this 14th day of April,


2019 at Santa Cruz, Laguna.

DEREK RAMSAY
Affiant

SUBSCRIBED AND SWORN to before me this 14th day of April 2019


at Santa Cruz, Laguna, Philippines and I FURTHER CERTIFY that I have
personally examined the affiant and I am satisfied that he/she has read and
personally understood the contents of her foregoing “Complaint-Affidavit”.

Piolo Pascual
Prosecutor II
Roll No. 51379-2006
IBP No. 808787-1/3/11
PTR No. 4128464- 1/3/11; Laguna
MCLE Compliance III No. 001360
Republic of the Philippines }
Province of Laguna }
Municipality of Santa Cruz }

AFFIDAVIT OF WITNESS

I, _____________, ____ years of age, single, resident of ______________________,


after having sworn in accordance with law, do hereby depose and state THAT:

1.

I executed this affidavit to attest the truthfulness of the foregoing facts and to
support the filing of Criminal Cases against _______________for violations of
________________.

AFFIANTS SAYETH NAUGHT.

IN WITNESS WHEREOF, I hereunto affixed my signature this 14th day of April,


2019 at, Santa Cruz, Laguna.

_________________

Affiant

SUBSCRIBED AND SWORN to before me this 14th day of April, 2019 at Santa
Cruz, Laguna. I HEREBY CERTIFY that I have personally examined the herein affiant
and I am satisfied that they voluntarily executed and understood their given affidavit.

Notary Public