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Republic of the Philippines


Branch __
_____Judicial Region
Bulwagan ng Katarungan
Magsaysay Blvd., _______________

PEOPLE OF THE PHILIPPINES, Crim. Case No. ______________


I, ____________________, of legal age, Filipino, married and a resident of
________________________, after having been sworn to in accordance with law do hereby
depose and say:
1. That I am the private complainant in above mentioned case;
2. That after careful recollection of the events, I have decided to withdraw and/or
desist, as I hereby withdraw and/or desist, from proceeding with the complaint against the
accused as it was really a result of a misunderstanding of the circumstances surrounding the
3. That I am not anymore interested to pursue the prosecution of the accused and I
pray for the dismissal of the instant case;
4. That my witnesses, if there are any, are no longer interested to testify before this
honorable court;
5. That I know that once this case is dismissed, I can no longer revive the same;
6. That this affidavit is executed voluntarily and on my own free will without any
threat, force, coercion or any single monetary consideration;
7. That the contents of this affidavit have been translated and fully explained to me
in the Waray-waray dialect and I have fully understood the same including its consequences.
IN WITNESS WHEREOF, I have hereunto set my hand this 17th day of July, 2019, in
Tacloban City.

Affiant/Private Complainant
Voter’s ID VIN: _________________________________

SUBSCRIBED and SWORN to before me this 17th day of July, 2019.

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