REPUBLIC OF THE PHILIPPINES

_______________

AFFIDAVIT OF DESISTANCE

I, ____________________________________, of legal age, Filipino, and a

resident of ________________________________________, after having been duly
sworn in accordance with law, hereby depose and say:

That I am the complainant, (or parent, guardian of

____________________________) against __________________________ driver of the
vehicle bearing Plate No. _____________________ for the injuries and or damages
which occurred on ____________________________________
at _______________________________________________________________
__________________________;

After a careful deliberation over the case, I found that the same does not merit or
warrant criminal prosecution as the injuries and or damages I suffered were purely
accidental;

That I am no longer interested in criminally prosecuting the case against the

aforementioned driver. For the reason that he/she gave his/her full support and
indemnified us in the amount of P_______________________________;

That this affidavit is being executed by me of my own free will and violation for
the purpose of seeking dismissal or signifying my intention to refrain from further
persecuting the aforementioned driver and waiving all rights and claims pertaining to said
accident now and here;

That the foregoing statement have been fully read by me and/or read and
translated to me in _____________________dialect, which I understand and that the
same are true and correct to the best of my knowledge and belief.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

___________ day of __________________ 2019 at _____________.

_________________________
Affiant

SUBSCRIBED AND SWORN to before me this ___________th day of

_____________ 2019, affiant exhibited his/her ID ___________________________

Doc No. _________

Page No. ________
Book No. ________
Series of 2019.