Republic of the Philippines )

City of Caloocan ) S.S.

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:

1. On January 4, 2010, at about 5:00 in the morning, while I was on my way to

work, I rode in one XXX Truck/PUB/ marked XXX., with plate number XXXXXX,
driven by XXX;

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;

4. As a consequence, standing passengers were then outbalanced causing me to

be pushed in the open door and I accidentally extended my right forearm outside
the bus;

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”;

7. As a result of the amputation of my right forearm, I incurred medical expenses

amounting to about Fifty Thousand Pesos (Ph50,000.0). This amount however
were all paid by the bus company, but as to the pain, trauma, and the permanent
disability on my part, they refuse to give any compensation, despite repeated
demand;

8. Before I suffered the traumatic amputation of my right forearm brought about by

the recklessness of the driver of XXX, I was gainfully employed at XXX earning a
monthly salary of XXX (PhpXXX) Attached herewith is a copy of the Certificate of
Employment, dated October 12, 2010 issued by my employer, marked as Annex
“C”;

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.

IN WITNESS WHEREOF, I have hereunto affix my signature this 26 th day of

January 2011, here at Caloocan City.

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.

Asst. City Prosecutor