REPUBLIC OF THE PHILIPPINES)

CITY OF MANDAUE ) S. S.

AFFIDAVIT OF DESISTANCE

I, _____________________________________________, of legal age, Filipino,

married, and a resident of __________________________________________________,
after having been duly sworn in accordance with law, hereby depose and state that :

1. On May 30, 2023, I was involved in a vehicular accident where I sustained

substantial physical injury;

2. As of the time of the execution of this Affidavit, I am currently confined in

Vicente Sotto Hospital for the treatment of said physical injuries;

3. After careful consideration and re-evaluation of the circumstances surrounding

the incident, I have decided to voluntarily withdraw and desist from pursuing
any criminal, civil, or administrative case against
______________________________________, the other individual involved in said
accident;

4. I am aware that this Affidavit of Desistance may have significant implications on

future or potential proceedings I may initiate, prosecute, and pursue, and may
result in the termination of the case;

5. I further affirm that my decision to withdraw the case is voluntary and without
any duress, coercion, or undue influence from any person, including the
abovementioned individual or third party;

6. I understand that by filing this Affidavit of Desistance, I am relinquishing any

claims, demands, or causes of action that I have or may have had against the
abovementioned individual;

7. I acknowledge that the same desistance does not affect any rights or claims that
other parties may have, and it shall not be construed as an admission of guilt or
liability on the part of the abovementioned individual;

8. In view of the foregoing, I finally manifest that I now completely and absolutely
exonerate ___________________________________________________ from any
liability in connection with the above-mentioned incident and that I am no longer
interested, and hereby desist, in any criminal, civil, or administrative action
regarding the complaint and pray that that the same desistance be a bar to any
civil, criminal or administrative claim against the abovementioned individual;

9. As such, I execute this Affidavit to certify or attest to the truth of the foregoing
facts and for whatever legal purpose that this Affidavit may serve.
 IN WITNESS WHEREOF, I hereunto set my hands this _________________ at
________________________________, Philippines.

____________________________________
Affiant
Government Issued ID No. _________________________

SUBSCRIBED AND SWORN to before me, this ________________________, by the affiant

who I have identified through competent evidence of identity and who exhibited their
Gov’t ID’s.

Doc. No.____;
Page No.____;
Book No. ____;
Series of 2023.