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Republic of the Philippines

City of ______

)
) S.S.
AFFIDAVIT

I,_______________________,
of
legal
age,
Filipino,
residing
at
__________________________________________,
hereby
accuse
_______________________ committing the act of EXTORTION as follows:
That on or about 12 midnight 1 am on 21 st of July 2016 in,
_________________________, I witnessed that the original intention of my
companion is to inquire how much will it cost to get my license back upon
confiscation due to my violation. The officer offered that it cost Php 1,000.00;
however, if I pay Php 500.00 to him he will no longer confiscate mu license
and deemed no violation has taken place. To my surprise I found out that it
will cost me Php 500.00 at the police station.
I have hereunto set my hand this _____ day of July, 2016, at City of
__________.

________________________
COMPLAINANT

SUBSCRIBED AND SWORN to before me, this 27th day of July 2016 by
____________________ who exhibited to me his/her _________________________
with ID Number ______________ issued at __________________, Philippines on
_________________, with date of expiry on ________________.

NOTARY PUBLIC

Doc. No.
Page No.
Boook No.
Series of 2016