REPUBLIC OF THE PHILIPPINES }

PROVINCE OF PAMPANGA }S.S.

CITY OF SAN FERNANDO }

JUDICIAL AFFIDAVIT

(of Jose Cruz taken by Prosecutor A in the presence of (witnesses, if any) on May 1, 2012 at
the Office of the City Prosecutor, City of San Fernando, Pampanga)

I, Jose Cruz, ____ years old, married, and a resident of

_____________________________, after subscribing under oath, deposes and states:

1. Question : Do you swear to tell the truth, the whole truth and nothing
but the truth in this judicial affidavit?
Answer : _________________________

2. Question : Please state your personal circumstances.

Answer : A. Name
B. Age
C. Residence/Business Address
D. Occupation

3. Question : What is your purpose in giving this sworn statement?

Answer : _________________________________

4. Question : On April 1, 2012, at around 5:00 o’clock in the afternoon,

where were you?
Answer : _________________________________

5. Question : What were you doing there?

Answer : _________________________________

6. Question : Who were with you, if there were any?

Answer : ___________________________________

7. Question : While you were in front of your home chatting with your
friends, what happened, if any?
Answer : ______________________________________

8. Question : When Pedro arrived and talked to you, what happened next,
if any?
Answer : ________________________________________

9. Question : After a heated argument between you and Pedro, what

happened next, if any?
Answer : __________________________________________

10. Question : What happened after he boxed you?

Answer : __________________________________________

11. Question : When he picked up a stone from the road, what did he do next, if
any?
Answer : __________________________________________

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12. Question : After he hit you with a stone on the head, what happened next, if
any?
Answer : _________________________________________

13. Question : Who pacified Pedro?

Answer : __________________________________________

14. Question : What did you do, if any, after your companion pacified Pedro?
Answer : __________________________________________

15. Question : When the Bantay-Bayan arrived, what happened next?

Answer : __________________________________________

16. Question : What did you do at the police station, if any?

Answer : __________________________________________

17. Question : Do you have proof that you caused the blotter of the
incident?
Answer : _________________________________________
Prosecutor : Witness presenting the original copy of the blotter dated
____________which we are marking as Exhibit “A”.

18. Question : What else did you do at the police station, if any?
Answer : __________________________________________

19. Question : Do you have that written statement with you?

Answer : __________________________________________
Prosecutor : Witness presenting the original copy of the statement dated
_________ which we are marking as Exhibit “B”.

20. Question : There is a signature on this Sworn Statement on top of the name
Jose Cruz, can you tell us whose signature is this?
Answer : __________________________________________

21. Question : After you made a statement at the police station, what did you do
next, if any?
Answer : __________________________________________

22. Question : Do you have evidence to prove that you indeed went to the
hospital?
Answer : __________________________________________
Prosecutor : Witness presenting the original copy of the medical certificate
which we are marking as Exhibit “C”.

23. Question : What expenses did you incur, if any, when you were treated
at the hospital?
Answer : __________________________________________

24. Question : Do you have proof to show that you incurred these expenses?
Answer : __________________________________________
Prosecutor : Witness presenting the original copy of the various receipts and
subscriptions which we are marking as Exhibit “D” to “D-
12”.

25. Question : For how many days/months did you take these medicines?
Answer : __________________________________________

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26. Question : How long were you confined at the hospital?
Answer : __________________________________________

27. Question : Do you have proof to show that you were indeed confined at
the hospital?
Answer : __________________________________________

Prosecutor : Witness presenting the original copy of a Certificate of

Confinement from the JBL Hospital which we are marking as
Exhibit “E”.

28. Question : At the time of the incident, what was your occupation, if any?
Answer : __________________________________________

29. Question : How much were you earning as such?

Answer : __________________________________________

30. Question : Do you have evidence to prove that you were indeed
employed as a _______________ and earning that much?
Answer : __________________________________________
Prosecutor : Witness presenting the original copy of his Certificate of
Employment and Compensation which we are marking as Exhibit
“F”.

31. Question : While you were treated at the hospital as a result of the
incident, were you able to report for work?
Answer : __________________________________________

32. Question : For how long did you take a leave of absence due to the injuries
you sustained?
Answer : __________________________________________

33. Question : Do you have evidence to prove that you were not able to report
for work for two (2) months?
Answer : __________________________________________
Prosecutor : Witness presenting original copy of the approve Application
for Sick Leave which we are marking as Exhibit “G”.

34. Question : If you will see Pedro again, will be able to identify him in court?
Answer : __________________________________________

35. Question : Are the documentary evidence you presented and identified
today the originals and/or duplicate originals?
Answer : __________________________________________

36. Question : Do you understand the questions asked of you and the
answers you have given in this judicial affidavit?
Answer : __________________________________________

37. Question : Are you fully conscious that the answers you have given in this
judicial affidavit are done so under oath?
Answer : __________________________________________

38. Question : Do you understand that you may face criminal liability for false
testimony or perjury if proven that you have stated any falsity
in this judicial affidavit?

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Answer : __________________________________________

39. Question : Are you willing to sign this statement?

Answer : __________________________________________

IN WITNESS WHEREOF, I have hereunto affixed my signature on this ____ day of

___________, 2012 at the City of San Fernando, Pampanga.

Affiant

Witnesses who were present or who assisted the affiant during the conduct of the question
and answer (if any):

_______________________ __________________________

SUBSCRIBED AND SWORN TO BEFORE ME on the ___ day of _____, 2012 at the
City of San Fernando, Pampanga.

Prosecutor

ATT E STAT I O N

I, Prosecutor __________________, upon being duly sworn, hereby deposes and states
that:

1. I supervised the examination of the witness;

2. I faithfully recorded or caused to be recorded the questions asked and the corresponding
answers that the witness gave;
3. I did not coach the witness/affiant regarding his/her answers; and
4. To my knowledge, no other person present in the preparation of this affidavit or assisting
the witness/affiant coached him/her regarding his/her answers.

IN WITNESS WHEREOF, I affixed my signature on the _____ day of ______, 2012 at

the City of San Fernando, Pampanga.

Prosecutor

SUBSCRIBED AND SWORN TO BEFORE ME on ___day of__________, 2012 at

the City of San Fernando, Pampanga.

Administering Officer