PAO FORM No.

2010-7

REPUBLIC OF THE PHILIPPINES)

) Ss.

AFFIDAVIT OF DESISTANCE
I, , of legal age, single/married, Filipino citizen and a
resident of , Philippines, after being duly sworn in
accordance with law, depose and state:

1. That I am the complainant in a criminal case docketed in the Regional Trial Court
of as Case No. against
;

2. That I am no longer interested in the prosecution of said case considering that the
facts and circumstances surrounding the instant case arose of misunderstanding and
misapprehension of facts between me and the accused.

3. I understand that the dismissal of my complaint against the accused/respondent

carries with it the dismissal of the civil aspect of the case, and the same can no longer be
re-instituted.

4. I am executing this affidavit voluntarily and free from any form of coercion,
compulsion or undue influence.

IN WITNESS WHEREOF, I have signed this Affidavit this day of

, 20 at the Municipality of _Province of
.

Affiant

SUBSCRIBED AND SWORN to before me this day of _, 20

at the Municipality of Province of , Philippines,
affiant showing to me

PAO Code Book 71 of 375

 ATTY.
Public
Attorney
(Pursuant
to RA
9406

PAO Code Book 72 of 375