Affidavit of Desistance Sample

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REPUBLIC OF THE PHILIPPINES )

Province of ______ ) S.S.

x---------------------------------------x

AFFIDAVIT OF DESISTANCE

I , ___________________, Filipino, of legal age, married, and a resident of


______________ after having been duly sworn in accordance with law, hereby
depose and state:

1. That I am the private complainant in the criminal case filed against


____________, which is recorded as ____________ before
______________ Province of __________ for ____________;
2. That I am no longer interested in the prosecution of the said case and that
I prefer to settle and put an end to this case;
3. That for and in consideration of this desistance, _______________ will
also desist in pursuing __________________ for ________________;
4. That he will receive the agreed medical assistance to be given by the five
(5) accused in _________________;
5. That we both agree to desist from filing any other cases related to the
subject incident that took place last ____________________-;
6. That by filing this Affidavit of Desistance I am aware that I can no longer
refile the said case in any other courts in the future;
7. That I have executed this affidavit in order to attest to the truth of the
foregoing circumstances and that my desistance to pursue said case is of
my own free will and volition and that there was no force, intimidation,
coercion or consideration that took place for me to make such decision.

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


________________.

__________________
Affiant

______________________ _____________________
Witness Witness

SIGNED, SUBSCRIBED, AND SWORN to before me by above affiant, at the place and on
the date first above written, known to me to be the same person who executed and swore
to their foregoing affidavit and that they acknowledged as their free act and voluntary deed.
I hereby certify that I have personally examined the above affiant under oath, and that I am
satisfied that he voluntarily executed and fully understood the contents of his foregoing
affidavit.

NOTARY PUBLIC
Doc. No. _______;
Page No. _______;
Book No. _______;
Series of 2019.

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