REPUBLIC OF THE PHILIPPINES)

Province Of ____________________) S.S.

City/Municipality Of_____________

x------------------------------------------x

COMPLAINT AFFIDAVIT

I, Jason Dyer, 25 years of age, single, Filipino citizen, a resident of Brgy. Bayanihan, Butuan City, after having been sworn to in accordance with law, do hereby depose and state:

1. That on November 1, 2011 at around 6 o’clock in the evening while I was heading home from the cemetery, I met Redentor Toro, Sr. at the corner of Intino Building along J. C. Aquino Avenue;

2. That without warning, he suddenly attacked me with a 2x2 piece of wood while saying “layuan mo sya! akin sya!”;

3. That despite being gripped to stop by the bystanders nearby, he still kept on attacking me while shouting “mang-aag aw ka!”;

4. That due to the said incident, I suffered a 8-inch wound in my head, a fractured left leg and two broken ribs due to the severe beating, and has been hospitalized for 16 days and advised to a complete rest for 4 weeks or more until my leg brace will be removed and my ribs will be completely healed.

5. I am executing this complaint-affidavit in order to file a case of Serious Physical Injuries against Redemtor Oja, Sr.

RELIEF

WHEREFORE, premises considered, it is most respectfully prayed unto this Honorable Court that, after hearing, judgment be rendered ordering the defendant:

1. To pay moral damages

2. To pay actual damages in the amount to be proved in court

3. To pay the plaintiff the cost of the suit;

4. Such other relief as the court may deem proper.

City of Manila, February 20, 2014.

FADERUGAO-FORTALEZA LAW OFFICE

Counsel for the Plaintiff

Unit 123, Victoria Tower I

Taft Avenue, Manila

By:

____________________________________

Roll of Attorney No. _____________

IBP No. _____________/______/______

PTR No. _____________/______/______

CERTIFICATION OF NON-FORUM SHOPPING

Republic of the Philippines)

Province of ____________________) S.S.

City/Municipality of _____________)

x - - - - - - - - - - - - - - - - - - - - - - - x

I, _____________, of legal age, Filipino, (single / married / widow), and a resident of _____________, Philippines, after being sworn in accordance with law, hereby depose and certify that:

1. I have not theretofore commenced any other action or proceeding or filed any claim involving the same issues or matter in any court, tribunal, or quasi-judicial agency and, to the best of my knowledge, no such action or proceeding is pending therein; (c) if I should thereafter learn that the same or similar action or proceeding has been filed or is pending before the Supreme Court, the Court of Appeals, or any other tribunal or quasi-judicial agency, I undertake to report such fact within five (5) days therefrom to the court or agency wherein the original pleading and sworn certification contemplated herein have been filed.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at _____________, Philippines.

________________________________________________________

AFFIANT

SUBSCRIBED AND SWORN to before me, this _____________, by _____________ who exhibited to me (his/her) Community Tax Certificate No. _____________ issued at _____________, Philippines on _____________.

Notary Public

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of 20__;