REPUBLIC OF THE PHILIPPINES }
PROVINCE OF BULACAN }S..S.
CITY OF SAN JOSE DEL MONTE }
JUDICIAL AFFIDAVIT
I, _____________________________, ____ year old, married/single/widow,
___(occupation)___ and a resident of _____________________________, after subscribing
under oath, deposes and states:
That Prosecutor _______________________, detailed at the Office of the City
Prosecutor, San Jose Del Monte City, Bulacan, 2/F Cangayo Bldg., Brgy. Gaya Gaya, this City,
conducts/supervises the examination of the affiant hereat the Office of the City Prosecutor, San
Jose Del Monte City;
That the undersigned affiant-witness is answering the questions asked of him/her, fully
conscious that he/she does under oath, and that he/she may face criminal liability for false
testimony or perjury;
Questions asked of the witness are as follows:
1. Q: Miss witness, are you the same complainant-witness in this case against the accused
_________________?
A: ____________________________
2. Q: How old are you?
A: 12 to 18 years old.
3. Q: On November 3, 2011, at around 6:00 o’clock in the evening, where were you?
A: ____________________________
4. Q: While waiting for a passenger jeep to go home, do you recall of any unusual incident
that happened?
A: ____________________________
5. Q: What was that?
A: ____________________________
6. Q: This person who invited you to ride in his car, why do you know him?
A: ____________________________
7. Q: For how long have you known him as a teacher in your school
A: ____________________________
8. Q: Were you able to reach your house on the said date?
A: ____________________________
9. Q: Why?
A: ____________________________
10. Q: What else did he tell you to persuade you to go with him to some other place other
your house?
A: ____________________________
11. Q: Where did you proceed after he promised to marry you if you go with him?
A: ____________________________
12. Q: What happened there?
A: ____________________________
13. Q: For how long did you stay there?
A: ____________________________
14. Q: How did your parents/relatives trace your where about?
A: ____________________________
15. Q: What happened after your parents/relatives, accompanied by the police, saw you in
that place where XY brought you?
A: ____________________________
16. Q: What did the police ask or require from you while in the police station?
A: ______________________________
17. Q: What else happened after you were investigated by the Women’ desk at the police
station?
A: ____________________________
18. Showing you this sworn statement given before the Women’s Desk of the San Jose Del
Monte Police, what relation, if any, has this to do with the statement you gave to the
police?
A: ____________________________
19. On page 2 of this document, there is a signature at the bottom thereof, who signed that?
A: ____________________________
20. Q: Were you examined by a doctor at the PNP Crime Laboratory Office?
A: ____________________________
21. Q: Were you issued a Medico Legal Report after examination?
A: ____________________________
22. Q: Do you have a copy of the Police Report?
A: ____________________________
23. Q: The attached Sworn Statement marked as Exh “A”, Police Report marked as Exh “B”,
Medico Legal Report marked as Exh. “C”, what relation do they have in relation to the
documents you earlier mentioned?
A: ____________________________
That the herein affiant warrants that the copy of document or reproduction attached to
this Judicial Affidavit is a faithful reproduction of the original thereof.
IN WITNESS WHEREOF, affiant has hereunto affixed his/her signature on this ____
day of ___________, 2012 hereat San Jose Del Monte City, Bulacan.
Affiant
SUBSCRIBED AND SWORN BEFORE ME on the date and place above mentioned.
Prosecutor
ATT E STAT I O N
________________________, upon being duly sworn, deposes and states:
1. That he supervised the examination of the witness;
2. He faithfully recorded or caused to be recorded the questions he asked and the
corresponding answers that the witness gave; and
3. Neither he nor any other person then present or assisting him/her coached the witness
regarding the latter’s answer.
IN WITNESS WHEREOF, he affixed his/her signature on the date and place first
written.
Prosecutor
SUBSCRIBED AND SWORN BEFORE ME on ___day of__________, 2012 hereat
the City of San Jose Del Monte, Bulacan.
Administering Officer
