REPUBLIC OF THE PHILIPPINES )

LEGAZPI CITY, ALBAY ) S.S.

AFFIDAVIT OF DESISTANCE

I, _________________, single, of legal age, Filipino, and a resident of ___________,

after being sworn to in accordance with law, hereby depose and state that:

1. I am the private complainant in Criminal Case No. ___________ for violation of

_______________________ against ________________, accused, docketed in
_____________________ , Branch ___;

2. ________________ asked for forgiveness for what he had done to me and I have
decided to forgive him. As such, I am no longer interested in prosecuting the
above-mentioned case against ______________ nor to testify against him in the
said case;

3. I respectfully request the Honorable Regional Trial Court of ______, Branch ___ and
the Honorable Provincial Prosecutor to DISMISS the above-mentioned case
against accused ____________________;

4. I am not forced, threatened, coerced or intimidated, and the execution of this

document is of my personal and voluntary act fully aware of the consequences
of the same that once this affidavit is fully executed I could no longer file a case
in court arising from the said incident;

5. I am executing this Affidavit of Desistance to attest to the truth of the foregoing facts
and to show that I am no longer interested in filing a case against
_____________ in any court of law or tribunal and for whatever lawful intent it
may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _______ at Legazpi City, Albay.

____________________________
Affiant

SUBSCRIBED AND SWORN to before me this __________ at Legazpi City, Albay, affiant
exhibited to me his ______________________________, as competent evidence of his identity.