Republic of the Philippines)

City of Tandag )S.S.

x-----------------------------------x

AFFIDAVIT OF DESISTANCE

I, _____________________, of legal age, Filipino, married,

and a resident of Brgy.____________, San Agustin, Surigao del
Sur, after having been duly sworn in accordance with law, hereby
depose and state:

1. That I am the mother of the minor child who was

accidentally hit by a vehicle driven by JOHN DOE while
traversing along national highway and on his way home to
Cortes, Surigao del Sur.

2. That I and JOHN DOE already executed an amicable

settlement before the barangay and a compromise
agreement wherein he promised to shoulder the expenses
for the hospitalization of my child in exchange of me no
longer pursuing any legal action against him in connection
with the said incident.

3. That I am no longer interested in the prosecution of any

case in connection with the aforementioned incident and I
hereby desist myself from filing any criminal complaint
arising out of the said incident. I likewise waive any and
all rights to institute said case in the future and I free
JOHN DOE from any responsibility or liability arising from
the said incident.

4. I am executing this affidavit voluntarily and free from any

form of coercion, compulsion or undue influence.

IN WITNESS WHEREOF, I have hereunto affixed my

signature this __________ at Tandag City, Surigao del Sur,
Philippines

_____________________
Affiant

SUBSCRIBED AND SWORN to before me this __________ at

Tandag City, Surigao del Sur, Philippines. For purposes of
evidence of identity, affiant exhibited to me her
_____________________.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2019.