AFFIDAVIT OF DESISTANCE I, _____________________________, Filipino, of legal age and presently residing at _________________ after having been duly sworn in accordance with law, hereby depose and say: 1. That
I am the complaining witness against ________________________ Driver/owner of the vehicle bearing Plate No. _________________________ and described as _______________________ for injuries sustained by me, ______________________ Death to __________________, and/or damage to property incurred as a result of a vehicular accident which occurred on _______________ at ___________________.
2. That the death/injuries sustained and/or damage incurred were purely
accidental in nature and does not warrant a criminal prosecution; 3. That I am not interested in prosecuting the aforementioned driver,
either civilly or criminally; 4. That this affidavit is executed by me of my own free will and volition for
the purpose of seeking dismissal or refraining from further prosecution whether criminally or civilly, the aforementioned driver, and/or owner of the above-described vehicle and hereby waive all present and future rights and pertaining to said incident; 5. That the foregoing statements have been fully read by me and/or read
translated to me in ______________ dialect which I speak and understand and which are true to the best of my knowledge. IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of ___________, at Digos City, Philippines. _____________________ Affiant Signed in the presence of ____________________ ___________________ SUBSCRIBED AND SWORN TO before me this ______ day of _____________ at Digos City, Philippines, affiant exhibiting to me his/her ID No. _______________________. Doc. No. ; Page No. _____; Book No. _____; Series of 2019.
ATTY. NORIBETH D. BAJENTING Notary Public – Davao del Sur Until 31 December 2020 Serial No. 183-2019 Roll No. 70552 PTR No. 2734620, 2/4/2019, Digos City IBP No. 62384, 6/27/2015, Davao Del Sur
