REPUBLIC OF THE PHILIPPINES )

Province of ____________________ ) S.S.

City/Municipality of ______________ )
x---------------------------------------x
AFFIDAVIT OF DESISTANCE
I, ________________(name of affiant)____________, Filipino, of legal age, [single]/[married to
_________(name of spouse)_________], and a resident of ___________________(address of
affiant)_______________, after having been duly sworn in accordance with law, hereby depose
and say:
1.
That
I
am
the
complaining
witness
for
__________________________________________________
against
_____________________________
in
the
case
entitled
_____________________vs.____________________, Criminal Case No. _________,
________(court branch)____;
2. That the accused, Mr/Mrs/Ms. _________________________ have paid me today
(___date___) the amount of ________________________________ Pesos (Php _____).
3. That in view of the payment in full by the accused, I would like to manifest that I am no
longer interested in the prosecution of the aforementioned criminal case.
4. I am respectfully requesting the Honorable Public Prosecutor to move for the dismissal
of
the
aforementioned
case
against
the
accused,
Mr/Mrs/Ms.
__________________________.

(Signature of Affiant)
____________________________
(Name of Affiant)
(JURAT)
_____________________________
Public Prosecutor