I, ____________, of legal age, Filipino, and with residential address at
__________________________, after being duly sworn in accordance with law, depose and state: - THAT -
1. I am the private complainant against accused _______________
in Criminal Case No. ________ for ____________ which is pending with the ______________ of ___________.
2. After a careful deliberation of the case, I had reached the conclusion
that the said accused had no real intention to commit the crime of violating the provisions of the Revised Penal Code on ___________;
3. In view thereof, as the private complainant, I am no longer interested
in the further prosecution of the aforementioned criminal case;
4. I am executing this affidavit freely, voluntarily, without force or
intimidation, and also without undue influence or promise.
5. I am executing this affidavit to attest to the truth of the foregoing
statements, and to cause the dismissal of the criminal case for ___________, which I filed against accused __________ before the _____________ of ________.
IN WITNESS WHEREOF, we have set our hand this ___ day of
_______ 2017, in _______, Philippines.
________________ Complainant/Affiant
SUBSCRIBED and SWORN to before me this ____ day of _______
2017 in ________, Bulacan, Philippines, and I hereby certify that I have personally examined the above-affiant and I am satisfied that she voluntarily executed and understood her affidavit.