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Supervisory Office and Investigation Agency (SOSIA-CSG)
Camp Crame, Quezon City Philippines


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

___________________________, after having duly sworn to in accordance with law,
depose and state:

1. I am a private complainant in Adminstrative case for violation of

__________________________ against ______________________ docketed as
Administrative Case No.______________ pending before the Regional Trial Court of
__________________, Branch ______.

2. After several conferences with the accused, I hereby declare that the same
arose out of pure misunderstanding and misapprehension of facts;

3. Based on the said misunderstanding, misapprehension of facts and also for

the welfare of my family, I manifest that I now withdraw my complaint against the accused
and that I am no longer interested and I hereby desist in prosecuting the above-mentioned

4. That the Affidavit of Desistance should however, not be understood as a

waiver or relinquishment of any of my _____________ rights to pursue any legal action
that I may file in connection with any act or omission that the accused may commit in the

5. I hereby release the accused from any and all criminal liabilities and waive
any right of action against the accused in connection with the above case;

6. I fully understand the legal consequences of this Affidavit of Desistance;

7. I a executing this affidavit to attest to the truth of the foregoing statement

and respectfully pray that the aforementioned case against _______________ be
withdrawn and / or dismissed.

IN WITNESS WHEREOF, we have hereunto set hands this

___________________ in ___________________________ Philippines.

Private Complainant

Assisted by:

SUBSCRIBE AND SWORN to before me this _______________ in
____________________. Philippines, affiant exhibiting to me her
_______________________ issued at _______________ issued on
___________________ as her valid proof of identification.

Doc. No.______:
Page No.______:
Book No.______:
Series of 2019.