AFFIDAVIT OF DESISTANCE

REPUBLIC OF THE PHILIPPINES)

) Ss.

AFFIDAVIT OF DESISTANCE
I, , of legal age, single/married, Filipino citizen and a resident
of , Philippines, after being duly sworn in accordance
with law, depose and state:

1. That I am the complainant in a criminal case docketed in the Regional Trial Court
of as Case No. against
;

2. That I am no longer interested in the prosecution of said case considering that the facts and
circumstances surrounding the instant case arose of misunderstanding and misapprehension of facts
between me and the accused.

3. I understand that the dismissal of my complaint against the accused/respondent carries with
it the dismissal of the civil aspect of the case, and the same can no longer be re-instituted.

4. I am executing this affidavit voluntarily and free from any form of coercion, compulsion or
undue influence.

IN WITNESS WHEREOF, I have signed this Affidavit this day of

, 20 at the Municipality of _Province of
.

Affiant

SUBSCRIBED AND SWORN to before me this day of _, 20

at the Municipality of Province of , Philippines.
affiant showing to me
AFFIDAVIT OF DESISTANCE