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City of ___________ )


I, ____________, of legal age, Filipino, and with residential address at

__________________________, after being duly sworn in accordance with
law, depose and state: - THAT -

1. I am the private complainant against accused _______________

in Criminal Case No. ________ for ____________ which is
pending with the ______________ of ___________.

2. After a careful deliberation of the case, I had reached the conclusion

that the said accused had no real intention to commit the crime of
violating the provisions of the Revised Penal Code on

3. In view thereof, as the private complainant, I am no longer interested

in the further prosecution of the aforementioned criminal case;

4. I am executing this affidavit freely, voluntarily, without force or

intimidation, and also without undue influence or promise.

5. I am executing this affidavit to attest to the truth of the foregoing

statements, and to cause the dismissal of the criminal case for
___________, which I filed against accused __________ before
the _____________ of ________.

IN WITNESS WHEREOF, we have set our hand this ___ day of

_______ 2017, in _______, Philippines.


SUBSCRIBED and SWORN to before me this ____ day of _______

2017 in ________, Bulacan, Philippines, and I hereby certify that I have
personally examined the above-affiant and I am satisfied that she voluntarily
executed and understood her affidavit.

Notary Public