Republic of the Philippines)

ISLAMIC CITY OF MARAWI. . . . . . . . . )SS.

AFFIDAVIT OF DESISTANCE &

QUITCLAIM

I, _____________________________, of legal age, Filipino and resident of

Purok 1, Bagumbayan, Kauswagan, Lanao del Norte, after having been duly sworn
to an oath in accordance with law, hereby depose and say:

1. That I the wife of the late __________________________, a victim of a

vehicular accident that took place on September 27, 2015, at around 9:40
in the evening at Brgy. Bubong, Sanguiaran, Lanao del Sur, involving
one (1) YAMAHA motorcycle color blue with sidecar, color blue,
bearing temporary plate number, driven by my husband
________________and one (1) KM451 army ambulance, color olive
drab, bearing plate Number: SLA-191 government vehicle, driven by
____________________, single, 30 years old, presently assigned at 65 th
IB, Brgy. Pawak, Saguiaran, Lanao del Sur;
2. That incident being purely an accident, I am not interested in filing a
criminal and administrative complaint against __________________ and
that I am desisting from filing the same and will not testify against him
should a case be called for investigation by the proper authorities;
3. That I am likewise quitting any claim against ____________________
and releasing him from any future liability as we have fully settled the
civil aspect of the incident amicably between ourselves;
4. That I am executing this Affidavit of Desistance and quit claim freely
and voluntarily and to attest to the truth and veracity of the foregoing
facts of my own personal knowledge and belief.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of

____________at Islamic City of Marawi, Philippines.

1
 _________________________________
Affiant

Signed in the presence of:

________________________________ ___________________________

SUBSCRIBED AND SWORN to before me this ______ day of __________

at Islamic City of Marawi, Philippines. Affiant exhibiting to me her Identification
Card.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of ______.