REPUBLIC OF THE PHILIPPINES)

Province of Agusan del Sur ) S. S.

Municipality of _________ )
X - - - - - - - - - - - - - - - - - - - - - - - -/

AFFIDAVIT OF DESISTANCE

I, ____________________, of legal age, single, Filipino and residing at Brgy.

______________________________, Agusan del Sur, Philippines, after having been
duly sworn to oath in accordance with law, do hereby depose and say:

That I am the guardian of _______________ and complainant against

_________________________ for the injuries as a result of an accident which occurred
on ________________, 2021;

That after a careful deliberation of the case, I found that the same does not merit
or warrant criminal prosecution as the injuries and or damages she suffered were purely
accidental;

That my witnesses have turned hostile and their whereabouts are now unknown
and without their testimonies, the case would not prosper and that I am no longer
interested in criminally prosecuting the case against the aforementioned company;

That this affidavit being executed by me of my own free will and violation for the
purpose of seeking dismissal or signifying my intention to refrain from further
prosecuting the aforementioned company and hereby waive all rights and claims
pertaining to said incident, now and hereafter;

That the foregoing statement have been fully read by me and/or read and
translated to me in Cebuan dialect, which I understood and that the same are true and
correst to the best of my knowledge and belief.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _________

day of _________, ____ in Bayugan, Agusan del Sur, Philippines.

________________________
(Affiant)

WITNESSED IN THE PRESENCE OF:

__________________________ ___________________________

SUBSCRIBED AND SWORN to before me this _________ day of _________,

____ in Bayugan, Agusan del Sur, Philippines. affiant exhibited to me his Residence
Certificate No. ________________ issued at ____________________________ on
______________________________.

Doc. No. ______

Page No. _____
Book No. _____
Series of 2021