JOINT COMPLAINT-AFFIDAVIT
OF THE COMPLAINANTS
Xxx AND xxx
THE UNDERSIGNED COMPLAINANTS-AFFIANTS
xxx and xxx, both of legal age and residing at xxx St., xxx Subdivision, xxx, xxx,
xxx City, under oath, respectfully state:
1.
RESPONDENT.
– The Respondent in this criminal complaint is xxx, of legal age, married, Filipino, and resident of Block xxx, Lot xxx, xxx
St., xxx Xxx, xxx, xxx, xxx, where summons/subpoenas may be served by this
Honorable Office for purposes of preliminary
2.
CRIME
CHARGED. – The herein Complainants hereby charge the abovenamed Respondent
for the crime of Perjury under Art. 183,
Rev. Penal Code, the ultimate facts
of which are discussed hereinbelow.
3.
ULTIMATE
FACTS. – On 14 December 2015, the Respondent executed a Sworn Statement before Asst. City Pros. xxx of the Office of the
City Prosecutor of xxx. A copy of the said sworn statement, together with the
related documents thereto (e.g., Police
Referral, dated 14 December 2015; Barangay Kasunduan, dated 7 October 2015;
Final Demand Letter, dated 12 November 2015; and Special Power of Attorney,
dated 14 December 2015) are attached hereto as Annex “A”, with sub-markings. In the said sworn statement, the
Respondent charged the herein Complainant XXX for the alleged crime of Estafa. It was docketed as xxx, entitled “xxx vs. xxx”.
It is undergoing preliminary investigation before Asst. City Prosecutor xxx.
3.1.
In Question
and Answer Nos. 4, 6, and 7 of the said Sworn Statement of the Respondent,
he perjuriously alleged the following statements of material facts under oath:
“x x x.
O4. T – Bakit mo e-reklamo
(sic) yung taong iyong nabanggit? (i.e., herein Complainant xxx).
S -
Dahil po sa hindi pag bayad sa akin ng perang hiniram nya na nagkakahalagang PhP326,000.00.
O5. T - Kailan, saan, at
anong oras naganap ang sinasabi mong pangyayari?
S - Ganito
po yun noong petsang nabanggit at nagkasundo po kami ni xxx na magnenegosyo
kung saan magpapahiram po kami sa kasamahan niyang xxx (sic) at may tubo poi
to, kaya sinimulan po namin ito sa akin po siya kumukuha ng pera at siya ang
nagpapalabas, noong unang buwan at maganda pa ang negosyo namin at bumabalik
and puhunan ngunit dumaan na ang ilang buwan kumukuha siya ng pera sa akin
ngunit hindi na ito bumabalik kasama na ang tubo at umabot na poi to ng
halagang PhP326,000.00 at noong kinausap ko na po siya ay puro kanalang PANGAKO
NG PANGAKO (sic).”
X x x.”
3.2.
The aforecited statements of the Respondent xxx under
oath were false and perjurious, the truth of the matter being that the Estafa complaint
filed by the Respondent (as Complainant therein) in the aforementioned case
against the herein Complainant XXX (as Respondent therein) was a perjurious,
malicious, felonious, baseless, unfounded and unjust FABRICATION intended by
the Respondent XXX: (a) To collect a loan that the herein Complainants had already paid in full; and (b)
To earn unjust, huge and usuri0us interests and/or penalties/surcharges on the
said fully paid loan, without any legal and contractual basis
therefor, and solely for the selfish
financial gain and benefit of the Respondent SAMPAMNG and his anonymous
Financier.
3.3.
The truth of the matter is that: The Complainant XXX does not owe any amount whatsoever
to the Respondent XXX ; and The act of the Respondent XXX of initiating the aforementioned
Estafa case against the herein Complainant XXX, without any legal and factual
basis, has caused him to suffer mental
anguish, extreme anxieties, sleepless nights, and besmirched reputation on the
part of the herein Complainants.
3.4.
The CHRONOLOGY
OF RELEVANT FACTS AND EVENTS in support of this Complaint for Perjury as discussed
hereinbelow.
3.5.
On 20
September 2014 or thereabout, the Complainant XXX was in need of P15, 000.00 for the tuition fees of his child enrolled at the xxx.
He sought the assistance of the Respondent. The Respondent said he could lend the
herein Complainant XXX the amount the latter needed. The Respondent said he had
enough personal savings to accommodate the urgent need of the Complainant XXX. The
Respondent did not mention that he would source the amount from an outside
Financier.
3.6.
On 30
September 2014, when the herein Complainant XXX was ready to pay in full his said P15, 000.00 loan,
the Respondent demanded an additional amount of P6, 000.00 as interest on the P15, 000.00 principal loan for the
period of ten (10) days. The Respondent alleged that the said amount was being required
by his anonymous Financier. The herein Complainant XXX was surprised by such a statement
of the Respondent because the latter had earlier said that the amount of P15,
000.00 was the Complainant’s own personal savings. The Complainants started to suspect the honesty of the Complainant.
The P6, 000.00 interest on the P15, 000.00 principal loan for a very short period
of ten (10) days was usurious,
unacceptable, unconscionable, iniquitous, and immoral. Nonetheless, to
avoid unnecessary interpersonal problems with the Respondent, the Complainants paid,
via a deposit to the bank account of the
Respondent, to the Respondent the principal loan of P15,000.00 and the
interest of P6, 000.00 that the Respondent and his anonymous Financier were demanding.
3.7.
As earlier stated, the Complainants paid the Respondent
on 30 September 2014 the total amount of
P21, 000.00, broken down as follows: (a) P15, 000.00 as principal loan; and
(b) P6, 000.00 as interest. Please note
that the said P6, 000.00 interest amounted to an incredible, usurious, iniquitous,
unconscionable and immoral forty percent
(40%) interest rate for the very short period of ten (10) days (i.e., 20
September 2014 to 30 September 2014).
3.8.
The abovementioned verbal loan transaction involving
a principal amount of P15, 000.00 that took place on 20 September 2014 was not evidenced by any promissory note,
contract of loan, voucher, official receipt, or similar financial or
contractual document. It was a verbal
loan transaction. There was no oral
or written stipulation whatsoever as to the interest, penalties, or surcharges of
the said verbal loan. Please note, too, that the Respondent did not attach to his Estafa Complaint any
promissory note, contract of loan, voucher, official receipt, or similar financial
or contractual document to prove his claim against the herein Complainants.
What were attached to the Respondent’s
Estafa Complainant were only the following documents: (a) Barangay “Kasunduan”
dated 7 October 2015 between the Complainant and the Respondent; (b) Final
Demand Letter, dated 12 November 2015, which was based solely on the
Barangay “Kasunduan”; and (c) Special Power of Attorney (SPA), dated 14 December 2015, executed by
the Respondent in favor of XXX (his daughter) and XXX (his sister) on the
pretext that he would be going abroad soon.
3.9.
Two (2) weeks after 30 September 2014 (the date
when the herein Complainants paid to the Respondent the said amount of
P21,000.00) -- or sometime in the middle
of October 2014, -- the Respondent called up the Complainant alleging: (a) That his anonymous Financier (whom
the Complainant did not identify) had allegedly rejected the payment of P21, 000.00 earlier made by the Respondent;
and (b) That the unidentified
Financier of the Respondent was allegedly demanding
double the said amount of
P21, 000.00, that is, a total of P42,
000.00. The Complainants rejected such an unfair, unjust, iniquitous,
unconscionable, immoral, usurious, and unacceptable demand for P42, 000.00.
3.10.
Please note that the Respondent’s demand for P42, 000.00 as of 15 October 2014 or
thereabout, in relation to the original verbal loan of P15, 000.00 contracted by the herein Complainant XXX on 20 September
2014, would amount to a huge and unjust interest of thirty-five percent (35%) for very short period of twenty-five (25)
days (i.e., 20 September 2014 to 15
October 2014). This was clearly usurious, immoral, unacceptable, iniquitous,
unconscionable, and unjustified, considering that no interest was formally agreed upon or stipulated when the verbal loan for P15, 000.00 was
consummated between the Complainant XXX and the Respondent on 20 September 2014. The Respondent did
not present to the herein Complainants at that time and up to the present time
any credible documentary proof identifying his anonymous Financier. Neither did
the Respondent present to the herein
Complainants at that time and up to the present time any documentary proof of demand/collection, statement of account, billing,
letter, or any written request or instruction from his anonymous Financier to
prove the allegation of the Respondent that his anonymous Financier was indeed demanding
P42, 000.00 at that time.
3.11.
The Complainants at that time demanded that the Respondent
the name, address and contact details of
the anonymous Financier so that the herein Complainants could personally
discuss and explain his position to the Financier. But the Respondent refused and
continues to refuse to this very day to give to the herein Complainants the
name, address and contact details of the anonymous Financier.
3.12.
After the said telephone call of the Respondent to
the herein Complainant XXX made on 15 October 2014 or thereabout, the Respondent
kept quiet for two (2) months. Then sometime
in December 2014 or thereabout the Respondent
again called up the herein Complainant XXX alleging that the past-due interest
of the latter on the original principal loan of P15,000.00 made on 20 September
2014 had already escalated to P100,000.00
as of the date of his call in December 2014. The Respondent alleged
that he had mortgaged his house to his anonymous
Financier to pay for the said unpaid interest of the herein Complainant XXX.
The herein Complainants, doubting the sincerity and truthfulness of the allegation
of the Respondent, demanded the name, address and contact details of the
Financier so that the herein Complainants could forthwith talk and discuss the issue
with the said Financier. They also demanded copies of any documentary proof justifying
the claim of P100, 000.00 interest as of that time (December 2014). But the Respondent failed and refused and
continues to fail and refuse to this very day to provide the herein
Complainants such information and documentary proof/s.
3.13.
On 7
October 2015 or thereabout the Respondent again called up the herein
Complainant XXX, saying that the former was at that time waiting inside Xxx Xxx
I Subdivision near the home of the herein Complainants, inside his van, and
that the Respondent wished to talk with the herein Complainant XXX for a while about
his loan. The herein Complainant XXX agreed to meet with the Respondent outside
his home. When they met, the Respondent asked the herein Complainant XXX to go
inside his van for a more private discussion. When the herein Complainant XXX the van of the
Respondent, he was surprised to see a man who identified himself as XXX XXX,
who showed the Respondent a government ID. XXX threatened the Respondent with
the following words:
“HOY, IKAW, LOKO KA HA! MAY UTANG KA PALA NANG GANITO
KALAKI KAY XXX. HINDI MO BA AKO KILALA? xxx AKO NG ASSOCIATION NG XXX XXX.
SUMAMA KA SA AKIN SA BARANGAY. PAG HINDI KA SUMAMA, PAPALABASIN KO KAYO SA XXX
AT HINDI NA KAYO PWEDE TUMIRA DITO.”
3.14.
Although the herein Complainant XXX, being a xxx
national, has no perfect mastery of the
Tagalog language, he understood the context of the threatening words of XXX
based on his facial expressions and hand movements and based on the harassing presence
of the Respondent. Despite the fact that there was no pending formal Barangay
complaint against the herein Complainant XXX and despite the fact that there
was no official Barangay summons issued to him at that time, he was forced by XXX
and the Respondent to go with them to the Barangay Hall of Barangay Xxx 5, Xxx Xxx
City right that very moment.
3.15.
At the Barangay Hall, the herein Complainant XXX
told the Barangay officer, by the name of “Deputy
xxx ”, (a) That he had not
received any formal Barangay complaint or formal Barangay summons; and (b) That
the claim of the Respondent for P366, 000.00 was baseless, unfounded, untrue,
false, and fabricated.
3.16.
The herein Complainant XXX, without the aid of an interpreter,
was forced by Barangay Deputy XXX, XXX, and the Respondent to sign a page of
the Barangay logbook, which turned out later to be a “KASUNDUAN”.
3.17.
The herein Complainant XXX was misled by
Barangay Deputy XXX, XXX, and the Respondent that the document was only a harmless record or minutes of the Barangay meeting. The contents and the legal effects of the said
document were not explained and
interpreted to the herein Complainant XXX by Barangay Deputy XXX or any
Barangay Kagawad or by the Barangay Secretary or by any Lupon Officer or
Member.
3.18.
The herein Complainant XXX signed the Kasunduan UNDER DURESS. He was MISLED by
Barangay Deputy XXX to sign it. He was threatened/intimidated by XXX and the Respondent
to sign it. He did not understand its contents, consequences, and legal effects
because, as a Japanese national, he has no mastery of English and Tagalog,
although he could understand and speak some simple conversational English and
Tagalog words. He was not assisted by an
Interpreter or by a lawyer of his choice. All he knew was that the said document
was a harmless minutes of meeting,
as represented to him by Barangay Deputy XXX, XXX and the Respondent.
3.19.
Later, in his criminal complaint for Estafa
against the herein Complainant XXX, the Respondent would capitalize on the said
KASUNDUAN as the sole basis of his FINAL DEMAND LETTER to prove the
alleged financial liability of the Complainant XXX. The Kasunduan was an entrapment document used by the Respondent to document a verbal loan agreement and to evade the
degree of evidence required by the Statutes
of Frauds of the Civil Code.
3.20. Aside
from the suspicious Kasunduan, the Respondent
has not presented any credible document, such as, but not necessarily limited
to, a CONTRACT OF LOAN, a PROMISSORY
NOTE, a VOUCHER, a STATEMENT OF ACCOUNT, or a BILL executed or signed by
the Lender and the Borrower: To prove the financial claim of the Respondent and
his anonymous Financier; To prove the
veracity of the computation/s of the usurious, unconscionable and iniquitous
interests of the herein Complainant XXX; and To prove compliance by the Respondent and his
anonymous Financier with the mandatory provisions of the TRUTH IN LENDING ACT in re: the
formal issuance by the Lender to the Borrower of a FULL DISCLOSURE STATEMENT, containing the amount of the principal
loan, the stipulated interest rate, the stimulated penalties and surcharges, if
any and other covenants related to the agreed loan.
3.21.
After a few days from 7 October 2015, the Respondent
made a series of calls to the herein Complainant XXX, pestering the latter to
pay his alleged obligation. The Respondent alleged and stated: That the payment
should be made by the herein Complainant XXX at the home of XXX, vice president of the homeowners association of
Xxx Xxx Subdivision (who was not a party
to the oral loan transaction); That the Respondent would soon leave for
abroad; That his wife would soon return from abroad; and That it would be a
great problem on his part if his wife would discover that he had mortgaged his house (and, this time, allegedly including his van)
to his anonymous Financier to secure the alleged obligation of the herein
Complainant XXX.
3.22.
Sometime in the latter part of October 2015 or thereabout the Respondent visited
the home of the herein Complainants, accompanied by an unidentified man whose
appearance appeared to be suspicious. The
Respondent repeated his demand to be paid, this time, in the total amount of P366, 000.00. The herein Complainants insisted that they
had already settled in full his original verbal loan of P15, 000.00 with P6,
000.00 interest. They demanded that the Respondent show proofs of the alleged liability
of the herein Complainant XXX and the computations of the alleged past-due
interests, either in the form of a voucher
or an official receipt or a statement of account or a billing or a promissory note
or a contract of loan or any other credible document. Ignoring the
foregoing demand of the herein Complainants, the Respondent insisted that the herein
Complainants pay the total amount he was claiming and that the same be paid by
them at the home of XXX. The Complainants were thus constrained to tell the Respondent
that it would be better for him to file a court case to prove his claim so that
the truth would come out.
3.23.
Please note that in the Barangay KASUNDUAN, dated 7
October 2015, the alleged financial obligation of the herein Complainant XXX,
according to the Respondent, was P366,
000.00. It contradicts the Final
Demand Letter, dated 12 November 2015, of the Respondent, which claimed the
total amount of P326, 000.00 - or a huge and unexplained difference of P40,
000.00.
3.24.
On 26 November 2015 the herein Complainant confronted
XXX at his home in Xxx Xxx Subdivision.
She brought along with her, as her mediators/witnesses, the Spouses XXX AND XXX.
Xxx was a past president of the homeowners association of the subdivision.
During the said confrontation, the Respondent was mysteriously present inside
the home of XXX. In that confrontation, herein Complainant XXX told XXX: That
the herein Complainants have been residents/tenants of the subdivision for
seven (7) years; That as the vice president of the homeowners association vested
with the legal duty to serve the common good of the homeowners/tenants of the
subdivision, XXX should have taken steps to protect the herein Complainants as
residents/tenants of the subdivision (i.e., as his constituents in the subdivision) against the baseless and unfounded
claim of the Respondent; That at the very
least XXX should have first consulted and heard the side of the herein
Complainants when the Respondent first sought his assistance to collect from
the herein Complainant XXX; and that he should not have believed outright, hook
line and sinker, the said claim of the Respondent without first giving the herein
Complainants an opportunity to be heard; That the act of XXX of coercively
bringing the herein Complainant XXX to the Barangay Hall on 7 October 2015, without
the assistance of the herein Complainant XXX and based solely on the personal request
of the Respondent -- and without the
prior filing by the Respondent of a formal Barangay complaint and without the
prior issuance by the Barangay Secretary of a formal Barangay summons to the
Complainant -- was an unjust, unfair, and illegal act of harassment,
intimidation, and unjust vexation.
3.25.
To put an end to abusive and pestering
collection behavior of the Respondent -- and solely to buy peace, without
admitting any liability on the part of the herein Complainants and without
admitting the validity of the claim of the Respondent in the amount of P366,
000.00 -- the herein Complainants paid
the Respondent an additional amount of P47, 000.00 on October 15, 2015,
via a deposit to the bank account of the Respondent, hoping that such an amount
would finally end the baseless claim and collection pestering/harassment of the
Respondent. But it was not so. The Respondent
continues to insist on his claim of P366,
000.00 by filing a harassment case for Estafa.
3.26.
The herein
Complainants believes that the Complainant is using the Criminal Justice System
as his own coercive COLLECTION AGENCY. It is the hope and prayer of the herein
Complainants that this Honorable Office would resist the malicious move of
the Complainant to use, mislead, and exploit it as his pro
bono personal COLLECTION AGENCY.
3.27.
On 26 November 2015, the herein Complainant XXX filed
a complaint with Barangay Xxx against
the Complainant and XXX. During the
Barangay conciliation XXX apologized
to her for his behavior. The herein
affiant accepted his apology, with the hope that XXX would be more discerning
as a community leader in the future.
3.28.
On January 18, 2016 at 7:00 PM, the Subpoena of
this Honorable Office in re: the Estafa case filed by the Respondent was delivered
by the process server of this Honorable Office at the new home address of the Respondent at Xxx Xxx Subdivision. (It was originally addressed to
the old home address of the herein
Complainants in the same subdivision). The herein Complainants was constrained
to retain the legal services of the LASERNA
CUEVA-MERCADER LAW OFFICES, Xxx Xxx City, to defend their legal and
constitutional rights, in the interest of truth and justice; to disprove the
false, fabricated, baseless, unfounded, and malicious claim of the Complainant;
and to file the necessary criminal and/or civil counter-charges against the
Respondent.
4.
CONTRADICTIONS
AND INCONSISTENCIES IN THE DOCUMENTS OF THE RESPONDENT. - Please note the internal contradictions and inadequacies
among the documents submitted by the Respondent in the Estafa case.
AS TO THE AMOUNT OF THE ALLEGED CLAIM:
(a)
In his Sworn
Statement, dated 14 December 2015, given before the Xxx City Police
Station, the Respondent claims P326,000.00;
(b)
In the Barangay
Kasunduan, 7 October 2015, he claims P366,000.00;
(c)
In the Final
Demand Letter, dated 12 November 2015,
he claims P326,000.00;
(d)
In the Special
Power of Attorney (SPA), dated 14 December 2015, he claims P326,000.00;
(e)
Please note that in all of the foregoing allegations
no VOUCHERS, OFFICIAL RECEIPTS, STATEMENTS OF ACCOUINTS, BILLS, PROMISSORY
NOTES, CONTRACTS OF LOAN, and/or DISCLOSURE STATEMENTS were presented by the Respondent
to prove his claim.
AS TO THE PURPOSE
OF THE ALLEGED LOAN OF THE HEREIN COMPLAINANT XXX.
(a)
In his Sworn
Statement, dated 14 December 2015, given before the Xxx Xxx City Police
Station, the Respondent alleged that he and the Respondent agreed to go into the business of money lending. (Q and A No. 6).
(b)
In his Special
Power of Attorney (SPA), dated 14 December 2015, he alleged that his claim
was based on alleged “Ticket
Purchase”. (Par. 1, SPA).
(c)
Please note that the Respondent has not
presented any proof of his alleged partnership
agreement or business
agreement with the herein Complainant XXX to establish a money lending business referred to in Q and A No. 6 of his Sworn Statement, dated
14 December 2015, e.g., AGREEMENT/CONTRACT,
MEMORANDUM OF UNDERSTANDING, ARTICLES OF PARTNERSHIP, AFFIDAVIT, UNDERTAKING,
DEED, LETTERS AND OTHER COMMUNICATIONS, and the like.
(d)
Please note, too, that the Respondent has not
presented any proof of the alleged “Ticket
Purchase” of the herein Complainant XXX, referred to in Par. 1 of his SPA, dated 14 December 2015, e.g., VOUCHERS,
PLANE TICKETS, BILLS, STATEMENTS OF ACCOUNT, UNDERTAKINGS, DEEDS, LETTERS AND
OTHER COMMUNICATIONS, and the like.
5.
The herein Complainants hereby submit to this
Honorable Office the following additional documents to support their instant
complaint for Perjury:
(a)
Annex “B”
– xxx Cash Deposit Slip #001281045029,
dated 30 September 2014, in the amount of P21, 000.00 paid to the bank account of the Respondent - to prove the full payment by the Complainants of
their oral loan dated 20 September 2014, broken down as follows: The agreed
principal loan of P15, 000.00; and The unstipulated
interest of P6, 000.oo demanded by the Respondent.
(b)
Annex “C”
and “C-1” – Barangay Blotter, dated 26 November 2015, re: the Barangay complaint
of the herein Complainant XXX against the unjust and coercive acts of
harassment of the Respondent and XXX XXX.
Note:
Due to lack of material time,
the herein Complainants cannot submit as an annex of this pleading at this time
a copy of the xxx Cash Deposit Slip,
dated 15 October 2015, in the amount of P47, 000.00 to prove that the herein Complainants had deposited the
said amount to the bank account of the Respondent to buy peace, without admitting any liability on the part of the herein
Complainant XXX and without admitting the validity of the claim of the
Respondent. The herein Complainants will
attempt this week to secure from the Bank a formal Certification of its Branch
Manager to corroborate the foregoing fact. The herein Complainants reserve the
right to present the said bank
certification as an annex to their future Reply-Affidavit. The said Cash Deposit Slip was misplaced or thrown away by the housemaid of
the herein Complainants, together with other personal papers, when their family
recently moved to their new home address
in the same subdivision. The housemaid
mistakenly thought that those papers were trash and unnecessary.
At any rate, please note that
the Complaint admits in Q and A No. 7 of his Sworn Statement, dated 14
December 2015, that he indeed RECEIVED
from the Respondent the said amount of P47,000.00.
6.
The herein Complainant XXX has REVOKED the
dubious, unfair, invalid, and misleading BARANGAY KASUNDUAN, dated 7 October
2015 (written in Tagalog, which is not
the mother language of the Complainant xxx), the reason being that he was
forced to sign the same UNDER DURESS, UNDER THE MISLEADING AND FALSE
REPRESENTATION of Barangay Deputy Xxx, in cahoots with XXX and the Respondent,
that the document was merely a harmless
record/minutes of the their Barangay meeting, and WITHOUT A FULL,
INTELLIGENT, AND VOLUNTARY KNOWLEDGE, CONSENT AND UNDERSTANDING OF THE LEGAL
EFFECTS AND CONSEQUENCES THEREOF on his part.
7.
ARTICLE 183 of the Revised Penal Code provides:
“Article 183. - False testimony in other cases and PERJURY in solemn
affirmation. — The penalty of arresto mayor in its maximum period to
prision correccional in its minimum period shall be imposed upon any person,
who, knowingly makes untruthful
statements and not being included in the provisions of the next
preceding articles, shall testify under oath, or make an affidavit, upon any material matter before a competent
person authorized to administer an oath in cases in which the law so requires.
Any person who, in case of a solemn affirmation made in lieu
of an oath, shall commit any of the falsehoods
mentioned in this and the three preceding articles of this section, shall suffer
the respective penalties provided therein.”
WHEREFORE, it is respectfully prayed
that the Respondent be indicted for PERJURY
under Art. 183 of the Rev. Penal Code and/or such other penal laws as may be
justified/warranted by the facts of this case.
FURTHER, the
herein Complainants pray for such and other reliefs as may be deemed just and
equitable in the premises.
Xxx Xxx City,
27 January 2016.
XXX XXX
Complainant
xxx St.
Xxx Subd.
Xxx City
XXX XXX
Complainant
Xxx St.
Xxx Subd.
Xxx City
SUBSCRIBED and sworn to before me in Xxx
Xxx City on ___ January 2016.
Administering
Assistant City Prosecutor
