Republic of the Philippines )

Province of ______ ) S.c.

Municipality of )______ )

AFFIDAVIT OF DESISTANCE

I, ______________, of legal age, widow, Filipino and a resident of

______________, after having been sworn to in accordance with law, do
hereby depose and state that:

1. I am the wife of the late ______________;

2. That on ______________, a vehicular accident transpired at

______________involving my husband, ______________, who was then
driving a ______________motorcycle with side car, and ______________,
who was then driving a ______________registered under the name of
______________., that resulted to the untimely demise of my husband,
______________;

3. Considering that the incident being purely an accident, I

am no longer interested in filing any criminal, civil or administrative
complaint against ______________and/or ______________., and am
desisting from filing the said. Hence, this Affidavit of Desistance;

4. In fact, I have already entered in an amicable settlement

with ______________and ______________.;

5. This decision is voluntary, without me being coerced or

forced by any other persons or officials.

6. I executed this Affidavit in order to attest to the truth of

the foregoing circumstances;

IN WITNESS WHEREOF, I have hereunto set my hand this

______________ at ______________.

Affiant
______________

SUBSCRIBED AND SWORN to before me this ______________ at

______________.