REPUBLIC OF THE PHILIPPINES)

CITY OF CABANATUAN ) S.S.

x-------------------------------------x

AFFIDAVIT OF WITNESS

I, RJ ACSINO, of legal age, Filipino, single and a resident of San Isisdro, after
having been duly sworn to in accordance with law, depose and state:

1. That I was present and personally saw that accused, __________, committed
the crime of _______________________ against the victim
__________________;

2. That ___________________________ (State other circumstances and the

relation either to the victim or accused or both);

3. That ___________________________ (State the details of the acts committed

by the accusedagainst the victim);

4. That ___________________________ (State the acts done by the witness and

the reason thereof);

5. That I executed this affidavit to attest the truthfulness of the foregoing facts and
to support the filing of criminal case against ____________________ for violation
of ________________________.

IN WITNESS WHEREOF, I hereby affixed my signature

this ___________________ in Makati City, Metro Manila, Philippines.

____________________

Affiant

SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant exhibiting to me his/her competent
evidence of identity by way of _________________ issued at ______________
on __________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2013