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


I, RICA CONGRESO, of legal age, single, and a resident of # 123 Main St., Kaskag,
Surigao, after having duly sworn to in accordance with law hereby depose and state:

1. I am the complaining witness for Serious Physical Injuries against Jessa Santos in the
case entitled "People of the Philippines versus Jessa Santos", Criminal Case No. 12345,
Regional Trial Court, Branch No. 29, City of Surigao.

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 Jessa 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 Surigao that I am withdrawing my complaint for
Serious Physical Injuries in Criminal Case No. 12345 entitled" People of the Philippines
versus Jessa Santos", Regional Trial Court, Branch No. 29, City of Surigao.

5. I likewise request the Regional Trial Court, Branch No. 29, City of Surigao 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 Surigao.

Juan de la Cruz

Complaining Witness

SUBSCRIBED AND SWORN to before me this 22nd day of January 2018 at the City of
Surigao, Philippines.

Arke June Park

Public Prosecutor