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Republic of the Philippines ) Province of________________ ) S.S.

City/Municipality of_________ ) x- - - - - - - - - - - - - - - - - - - - - -x


I, ________________, of legal age, (single/widow/married to _____________________), Filipino citizen, and a resident of _______________, Philippines, after being sworn to in accordance with law, depose and state:

1. That I am the complainant in Criminal Case No.__________for alleged "RAPE" against accused___________, which case is pending before the Regional Trial Court, Branch______, City/Municipality of _____________, Philippines;

2. That I signed the aforesaid complaint against accused _________________ against my will, my signature in the complaint having been obtained thru force, violence and intimidation done to me by my parents;

3. There is no truth to the allegations contained in my sworn statement executed by me against my will on ___________ at ____________, taken by ____________. There was no force, violence or intimidation done against me by said accused___________. I was not forced by him to submit to his desires. It was all in accordance with my own will, volition and consent that I went personally to him because we love each other and I agree and consent to live with him as my husband;

4. I therefore respectfully request that the above-mentioned case filed against said _________________ be dismissed as in fact I now withdraw my complaint against him and I further manifest under oath that I am now desisting from testifying against him in Court or in any other government entity or agency in connection with the said criminal case.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of ___________, 20____ at Barangay ___________, __________, ____________, Philippines.