AFFIDAVIT OF DESISTANCE

I, __________________________________, of legal age, Filipino, and a resident

of _______________________________________________, after having been sworn in
accordance with law, depose and state:

1. On 15 December 2012, I was accidentally hit by a vehicle driven by certain,

Micki Quimbo.

2. Pursuant to the settlement reached by the parties, I am no longer interested

in prosecuting any and all cases, whether criminal, civil and/or
administrative, and would like to desist from further prosecuting the same.

3. I hereby release, forever discharge and quit any or all claims against Micki
Quimbo relating to any and all liabilities, claims, demands, actions, cause of
action, suits at law or equity, of whatever nature and kind, arising out of the
accident mentioned above.

4. I am executing this Affidavit of Desistance to seek the dismissal or refrain

from further prosecution of Micki Quimbo, whether criminally or civilly,
and to waive, as I hereby waives all present and future rights and claims
pertaining to the accident mentioned above.

5. I am executing this Affidavit of Desistance of my own free will and

volition.

IN WITNESS WHEREOF, I have hereunto set my hand this 3rd day of September
2009 at Manila, Metro Manila.

_______________________________

SUBSCRIBED AND SWORN to before me this ___ of December 2012 in

___________ City, affiant exhibiting to me his evidence of identity, ____________ No.
_____________.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2012.