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Republic of the Philippines )
Municipality of Kalibo, Aklan ) s.s.
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COMPLAINT AFFIDAVIT
That I, _______________ , of legal age, Filipino and a resident
of Kalibo, Aklan, after having been duly sworn to according to law hereby depose and say:
1. That I am the _____________ of Municipality of Kalibo,
Aklan. I am executing this affidavit in behalf of said municipality, being the complainant herein; 2. In behalf of the said municipality, I am filing a formal complaint for Violation of Section ____ of Municipal Ordinance No. 2016-008 otherwise known as “AN ORDINANCE PROHIBITING THE USE, SALE, DISTRIBUTION AND ADVERTISEMENT OF CIGARETTES AND OTHER TOBACCO PRODUCTS, AND ELECTRONIC CIGARETTES, IN ALL PUBLIC PLACES, IMPOSING PENALTIES FOR VIOLATIONS THEREOF AND PROVIDING FUNDS THEREFOR, AND FOR OTHER PURPOSES” against respondent _________, a resident of _________, _______, Aklan. A copy of said ordinance is attached as “Annex A”; 3. That on ___________, about _____________ in the morning/afternoon, respondent was caught smoking in ___________________. The said violation constitutes as a first/second/third offense under abovementioned ordinance and he/she was issued a citation ticket with Ticket No. ________________. Attached herein is a copy of the said citation ticket as “Annex B”; 4. That respondent was informed to pay/settle his fine within five (5) days at the Municipal Treasurer’s Office, Municipality of Kalibo otherwise the Municipality shall be constrained to file a case against him/her; 5. That after five (5) days upon issuance of ticket, respondent failed to pay the fine imposed at the Municipal Treasurer’s Office, Municipality of Kalibo; 6. That a demand letter dated __________ was sent to respondent to require him to settle his obligation after _____ days upon receipt. Attached herein is a copy of said letter as “Annex C”; 7. That until now, respondent has failed to settle his obligation; 8. That I am executing this affidavit for and behalf of the Municipality of Kalibo, being the ___________ thereof, to file a formal complaint for Violation of Section 5(a) of Municipal Ordinance No. 2016-008 against _________________.
IN WITNESS WHEREOF, I have hereunto affixed my
signature for and in behalf of the complainant Municipality of Kalibo this ____ day of August 2018, at Kalibo, Aklan.
_______________________
AFFIANT ID No.__________________
SUBSCRIBED AND SWORN to before me this ___ day of
_______ at _______________. I HEREBY CERTIFY that I have personally examined the herein offended party and I am satisfied that they voluntarily executed and understood their given affidavit.