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COMPLAINT-AFFIDAVIT
I, XXX, of legal age, Filipino, married and a resident of XXX, after having duly
sworn to in accordance with law hereby depose and say that:
2. Considering that the bus was already full of passengers then, I was forced to be
in standing position at the stepping board situated at the middle door of the bus;
3. While the bus was traveling along XXX, heading towards XXX, from north to
south, it executed an abrupt right turn;
5. In the process, my right forearm was pinned in between the concrete post and
the middle portion of the body of the moving bus and which resulted to the
outright amputation of my right forearm. Attached herewith is a copy of the Traffic
Accident Report dated January 4, 2010, prepared by XXX of the Philippine
National Police, marked as Annex “A”;
6. I was then rushed to XXX for medical treatment. Attached herewith is a copy of
the Medico Legal Certificate dated January 4, 2010, issued by the hospital,
marked as Annex “B”;
9. When the incident happened, I was only fifty five (55) years old thus, I was
deprived of ten (10) more years of employment before mandatory retirement.
Attached herewith is a copy of my Certificate of Live Birth, marked as Annex
“D”;
10. I am filing this case as indigent litigant thus, must be exempted from filing fees
and all other fees relative to the filing of this case. Attached herewith is a copy of
the Certificate of Indigency dated 31 August 2010, issued to me by Barangay
178, Caloocan City, marked as Annex “E”;
11. I am executing this affidavit to attest to the truth of the foregoing statements and
for the purpose of charging XXX, for the crime of Reckless Imprudence resulting
to Serious Physical Injuries, with Damages under Article 365 of the Revised
Penal Code.
XXX
Affiant
SUBSCRIBED AND SWORN to before me, this 26th day of January 2011, here at
Caloocan City.
Further, I hereby certify that I have personally examined the affiant and I am fully
satisfied that he voluntarily executed his affidavit.