Republic of the Philippines )

[CITY] ) s.s.

COUNTER-AFFIDAVIT
Re: I.S. No. ____________

[1] I, [NAME] _______________, of legal age, with assistance of counsel, do hereby

state under oath that:

1. I am [STATE PERSONAL CIRCUMSTANCES OF COMPLAINANT-AFFIANT]

____________________________.

2. I recently learned that I have been made a respondent in I.S. No.

__________________, a charge for [CRIME CHARGED] ______________, filed by a certain
[NAME] ______________ on [DATE] ________________ before the Office of the City
Prosecutor for [CITY] ________________.

3. The charge is based on [STATE CIRCUMSTANCES ALEGEDLY SURROUNDING

THE CRIME CHARGED] _______________________________________.

4. There is no truth to the allegations in [NAME OF COMPLAINANT]s complaint.

There is no factual nor legal basis to charge me with [CRIME CHARGED] ______________.
The Complaint must be dismissed. To rebut and contradict [NAME OF COMPLAINANT]s
malicious lies, I set forth the true circumstances leading to the transaction below:

4.1. [STATE FACTS TO SHOW THAT NO CRIME WAS

COMMITTED] ____________________________________________.

5. . [STATE FACTS TO SHOW THAT NO CRIME WAS COMMITTED]

____________________________________________.

6. For this reason, it is certainly incomprehensible that I should stand accused of

[CRIME CHARGED] _________ by [Mr./Ms. NAME OF COMPLAINANT]
_____________________. [STATE OTHER REASONS FOR LACK OF CRIMINAL
LIABILITY] _____________________________________.

7. Considering the foregoing, I respectfully submit that there is no prima facie basis
to conclude that the crime of [CRIME CHARGED] _____________________ or that any
crime at all has been committed. The Complaint against me should, thus, be dismissed.

TO THE TRUTH OF THE FOREGOING, I have signed this Statement on [DATE]

________________.

[SIGNATURE]
[NAME] ______________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this _________ day of [MONTH] ______

[YEAR] ___________.

[SIGNATURE]
Investigating Prosecutor

CERTIFICATION

I HEREBY CERTIFY THAT I HAVE PERSONALLY EXAMINED THE AFFIANT AND

AM SATISFIED THAT HE VOLUNTARILY EXECUTED AND UNDERSTOOD HIS AFFIDAVIT.
 [SIGNATURE]
Investigating Prosecutor