REPUBLIC OF THE PHILIPPINES)

C I T Y O F _______________________)S.C..

AFFIDAVIT OF DESISTANCE

I, _______________________________ of legal age, married and residing at

________________________________________, after having been sworn to in accordance with law
hereby depose and say, that:

I are the complainant in I.S. No. IV-15-INV-___________________ for Frustrated Homicide

against ____________________________ which case is pending before the City Prosecutor’s Office,
_____________________________;

I am are no longer interested in the further prosecution of the aforementioned case

against the said accused as I have fully pondered that the filing of the case was a result of
misunderstanding and misapprehension of facts;

I am informing and formally requesting the Honorable Office of the City Prosecutor of
______________________________ that with the execution of this affidavit, a commensurate motion
to dismiss should come next to be initiated by the Public Prosecutor;

This affidavit is executed freely and voluntarily; and that no force, intimidation, undue
influence or duress was employed nor any monetary consideration was promised or offered
for the execution of this affidavit;

I am executing this affidavit in order to attest to the truthfulness of all the foregoing
and to tell the proper authorities concerned for whatever legal purposes that this affidavit
may serve.

IN WITNESS WHEREOF, I have hereunto set our hand this 10th day of January, 2013
at Lipa City, Philippines.

_________________________________
Affiant/Complainant

SUBSCRIBED AND SWORN to before me this 10th day of January, 2013 at Lipa City,
Philippines.

______________________
Administering Officer

CERTIFICATION

I hereby certify that I have personally examined the affiants/complainants and that I
am fully satisfied that they voluntarily executed and understood their affidavit.

Administering Officer