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AFFIDAVIT OF DESISTANCE

REPUBLIC OF THE PHILIPPINES)

CITY OF MANILA ) S.S.

(the persons and circumstances below is fictional, please revise)

I, Juan del la Cruz, of legal age, single, and a resident of # 123 Main St., Malate, Manila, after having
duly sworn to in accordance with law hereby depose and state:

1. I am the complaining witness for Serious Physical Injuries against Jesus Santos in the case entitled
"People of the Philippines versus Jesus Santos", Criminal Case No. 12345, Metropolitan Trial Court,
Branch No. 11, City of Manila.

2. After my sober and soul searching assessment and analysis of the incident, I have realized that
because I was not wearing my eyeglasses and it was dark, I can not point out, without a doubt the
accused or any other person/s who inflicted harm against me.

3. Since I could not state with certainty and without doubt the liability of Jesus Santos, in fairness to
him, I am permanently withdrawing my complaint against him. I clear him of whatever responsibility or
liability to me.

4. I hereby inform the City Prosecutor of Manila that I am withdrawing my complaint for Serious
Physical Injuries in Criminal Case No. 12345 entitled "People of the Philippines versus Jesus Santos",
Metropolitan Trial Court, Branch No. 11, City of Manila.

5. I likewise request the Metropolitan Trial Court, Branch No. 11, City of Manila to dismiss with
prejudice the said criminal case.

IN WITNESS WHEREOF, I hereby set my hand this __ day of September 20__ at the City of Manila.
Juan de la Cruz

Complaining Witness

SUBSCRIBED AND SWORN to before me this 22nd day of January 20__ at the City of Manila, Philippines.

Romeo Abad

Public Prosecutor