REPUBLIC OF THE PHILIPPINES )

City of ___________ )

AFFIDAVIT OF DESISTANCE

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.

________________
Complainant/Affiant

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