Republic of the Philippines )

Province of Leyte )
Municipality of Villaba ) S.S.
x-----------------------------------x

AFFIDAVIT OF DESISTANCE
I, JERWIN LUCHAVEZ, of legal age, with live-in partner, Filipino and a resident of
Brgy. Mahanglad, Villaba, Leyte, Philippines, after having been duly sworn to in accordance
with law, do hereby depose and state:

1. That I am the Private Complainant of a Criminal Case for Serious Physical Injuries
and/or any other necessary crimes committed to me by one JASON LIRASAN on
December 26, 2017 at around 6 o’clock A.M. at Brgy. Mahanglad, Villaba, Leyte;

2. That I am executing this Affidavit to attest and certify to the truth that I am no
longer interested in the further prosecution of this case against the accused,
JASON LIRASAN, because said JASON LIRASAN promised to pay me for my
medical expenses in the amount of ₱10,000.00 and any further expenses to be
incurred by me until I will be capacitated to go back to work.

3. That further, I hereby make manifest that I am no longer interested in the further
prosecution and/or investigation of this case against accused JASON LIRASAN
that is now pending before the Municipal Police Station of Villaba, Leyte.

4. That I am executing this affidavit to attest to the truthfulness of the foregoing

statements for all legal intents and purposes.

IN WITNESS WHEREOF, I have affixed my signature below this ____th day of

__________________, 2018 at _______________________, Philippines.

JERWIN LUCHAVEZ
Affiant/Complainant

With Consent:

JASON LIRASAN
Accused

SUBSCRIBED AND SWORN to before this ____th day of _______________, 2018 at

________________________, Philippines, by Affiant who is personally known to me and/or who
exhibited her competent evidence of identity issued on _____________________ at
___________________________, Philippines.

NOTARY PUBLIC
Doc. No. _______;
Page No. _______;
Book No. _______;
Series of 2018.