IN THE DISTRICT COURT IN AND FOR TULSA COUNTY STATE OF OKLAHOMA STATE OF OKLAHOMA, Plaintiff, vs. ______________________________, Defendant.

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Case No.

COMPLAINING WITNESS VOLUNTARY APPLICATION TO DISMISS I, ____________________________, of lawful age, having been duly sworn do hereby certify and state that I am the Prosecuting Witness or Victim in the above named case, wherein the Defendant has been charged with a crime. That I hereby certify under oath that I am not under the influence of any drugs or alcohol, there are no medications which I have been prescribed that I have not taken, that I have not been promised anything, threatened, forced, or otherwise unduly influenced to execute this document requesting that the above referenced charge(s) be dismissed. Further, I certify that I am competent and fully understand the consequences of this document and I am aware that I have the right to seek independent legal advice regarding this matter and that I have or can do so to my satisfaction. I am also aware that the attorney for the Defendant does not represent me or my interests. I also understand that the District Attorney’s office may choose not to dismiss this case even though I am requesting that it be dismissed. Further, I understand that this case cannot be re-filed at any time if it is dismissed upon my request. I freely and voluntarily request that the case against the Defendant named above be dismissed and I request the District Attorney’s office not prosecute the Defendant for the following reason(s): ___________________________________________________________________ ___________________________________________________________________ Signature:________________________________ Complaining Witness Print Name:______________________________ SUBSCRIBED AND SWORN to before the undersigned notary public on this _____ day of ______________, 200___. My commission expires:________________ _____________________________ NOTARY PUBLIC

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