Republic of the Philippines)

City of Sorsogon ) Sc.

AFFIDAVIT OF DESISTANCE

I, ____________________, of legal age, Filipino and a resident of 2747 Quezon

St. Sorsogon Capital, Sorsogon City, after being sworn in accordance with law, do
hereby depose and state:
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1. That I am the owner/driver of a private vehicle, bearing plate No.
___________ , Chassis No. MR0GB8DD201315074, Engine No. 2GD0036022,
with CR No. 224131110 dated 09/08/2015, OR No. 774483135 dated
09/08/2015;

2. That on January 13, 2017 on or about 8:30 in the morning at along Brgy. Rizal,
__________________, while I was driving my vehicle, an Isuzu Truck, bearing
plate No. MVY528, Engine No. 6HH1-250077, Chassis No. FRR33H4-3000625,
CR No. 11764002-5, OR No. 906393025, registered to Sultan Kudarat Milling &
Trading Inc. and being driven by __________________., holder of Professional
Drivers License No. M02-03-068194, restrictions 1,2,3 valid until 06/27/2018,
accidentally/hit my vehicle resulting damages to my vehicle;

3. That due to the incident, my vehicle incurred damages at the tail light,
driver’s side;

4. That considering that the driver/owner of the Isuzu Truck has acknowledged
the incident and has agreed to shoulder the expenses incurred for the repair of
my Vehicle, I have decided not to file any claim against thereto arising from
the event;

5. That I voluntarily desist from pursuing any action arising the incident
knowing fully well the consequences of this desistance;

6. That I have willingly and voluntarily executed this affidavit;

7. That I am executing this affidavit to attest to the foregoing facts.

In witness whereof, I have hereunto affixed my signature this ___th day of

____________ at Sorsogon City.

__________________________-

SUBSCRIBED AND SWORN TO before me this ___th day of

______________ at Sorsogon City, affiant having exhibited to me his LTO Drivers
_______________