AFFIDAVIT OF DESISTANCE

REPUBLIC OF THE PHILIPPINES)

MUNICIPALITY OF BAYAMBANG ) 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 Serious Physical Injuries against

_____________________________ in the
case entitled __________________________ Criminal Case No.
_____________, Metropolitan Trial Court, Branch No. 11, City of Manila.

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 the City Prosecutor of Manila that I am withdrawing

my complaint for Serious Physical Injuries in Criminal Case No.
12345 entitled _______________________", Metropolitan Trial Court, Branch No.
11, City of Manila.

5. I likewise request the Metropolitan Trial Court, Branch No. 11, City of Manila
to dismiss with prejudice the said criminal case.

IN WITNESS WHEREOF, I hereby set my hand this __ day of September 20__

at the City of Manila.

Juan de la Cruz
Complaining Witness
SUBSCRIBED AND SWORN to before me this 22nd day of January 20__ at the City
of Manila, Philippines.

Romeo Abad
Public Prosecutor