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Republic of the Philippines )

Province of _____________ ) S.S.


City of _________________ )
x-----------------------------------x
AFFIDAVIT OF DESISTANCE
I, ____________________________________________ of legal age, Filipino and a
resident of _______________________________________________________, after having
been duly sworn to an oath in accordance with law depose and say:
1. That I am the same person executing this affidavit;
2. That I am the complaining witness for ____________________________________
against
________________________________________
in
the
case
entitled _____________________________________________, Criminal Case No.
_________________, ___________ Trial Court, Branch No. _______________,
_____________________________, _____________________________, Philippines;
3. That after my sober and soul searching assessment and analysis of the incident, I have
realized that because (reason for desistance);
4. Since I could not state with certainty and without doubt the liability of
_______________________________________ in fairness to him/her, I am permanently
withdrawing my complaint against him/her. I clear him/her of whatever responsibility or
liability to me.
5. I hereby inform the (Municipal/City/Provincial Prosecutor) that I am withdrawing my
complaint for ______________________________ in Criminal Case No.
_______________
entitled _____________________________, ________________
Trial
Court,
Branch
No.
_________________,
__________________________________, Philippines.
6. That I likewise request the __________________________ Trial Court, Branch No.
____________________, _____________________________, to dismiss with prejudice
the said criminal case.
7. That we are executing this affidavit to attest to the truth of the foregoing and for whatever
lawful purpose that it may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this ______ day of
__________________, 2016 at __________________________________________.
_________________________
Affiant
ID No. ___________________
Issued by: ________________
Issued on: _________________

SUBSCRIBED AND SWORN to before me this ____ day of ______________, 2016 at


_______________________________________.
Doc No. _____________
Page No. ____________
Book No. ____________
Series of 2016.