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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:
That I am the private complainant in the criminal case for alleged Theft docketed as
____________ before ___________Trial Court, Branch _____, __________, ______________,
That I found out that the said accused at the time of the incident was not in his right mind
and did not know that what he was doing was wrongful and criminal considering that he was
suffering from Schizophrenia, Paranoid Type in acute exacerbation as certified to by Dr.
____________ of ____________;
That the items taken by the accused, consisting of ____________ and ____________
were immediately recovered from him and their values had been voluntarily reimbursed by the
relatives of the said Accused;
In view of the foregoing, I finally manifest that I now completely and
absolutely exonerate the accused __________ from any liability in connection with the abovementioned criminal case and that I am no longer interested, and I hereby desist, in prosecuting the
said criminal case;
That I execute this Affidavit of Desistance so that the above-mentioned criminal case be
immediately dismissed and considered finally closed and the bond posted by the herein accused
be released to him;
As such, I am respectfully praying that the aforementioned case against the
Accused____________ be dismissed and finally closed.
IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day of
___________, 20____ at Barangay ___________, __________, ____________, Philippines.