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CITY OF _________ ) S.S.

I, ____________________, of legal age, single, and a

resident of ______________________________, after having
duly sworn to in accordance with law hereby depose and state:

1. I am the Private complainant for __(case title)______

against ___(defendant)___________ in the case docketed as
______(case number)__________ before __(venue either rtc or
metc)________, City of _________.

2. After my sober and soul searching assessment and

analysis of the incident, I have realized that because I was not
wearing my eyeglasses and it was dark, I can not point out,
without a doubt the accused or any other person/s who inflicted
harm against me.

3. Since I could not state with certainty and without doubt

the liability of Jesus Santos, in fairness to him, I am
permanently withdrawing my complaint against him. I clear him
of whatever responsibility or liability to me.

4. I hereby inform this honorable court that I am

withdrawing my complaint for _(offense complained
for)___________ in Criminal Case No. _____________
entitled _________________, before ___________________,
________________, City of __________.

5. I likewise request the __(venue either rtc/metc)__, City

of ________ to dismiss with prejudice the said criminal case.

IN WITNESS WHEREOF, I hereby set my hand this __ day

of ___________20__ at the City of ________.

SUBCRIBED AND SWORN TO before me this _____ day
February 2017 at the City of _______ and I do CERTIFY that I
have examined the affiant and am convinced that he had read
and understood the contents of his statement and did executed
the same freely and voluntarily.


Doc No. _____;

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