REPUBLIC OF THE PHILIPPINES )

__________________________________ ) S. S.
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AFFIDAVIT OF NO INTEREST TO FILE CRIMINAL CHARGES

I, (Name of Affiant), of legal age, Filipino, (civil status) and a resident of

____________________, Philippines, after being sworn to according to law, depose and say, that:

1. That I am a victim of ___________________ that happened on or about (time of the incident)

while (state the activity or actual incident) in ______________________________, Philippines;

2. That (state the reason of desisting or grounds of your lack of interest to pursue the charges);

3. In view of the foregoing, I hereby confess, declare and manifest my ABSOLUTE LACK
OF INTEREST and PERMANENT DESISTANCE from filing any suit, whether criminal,
civil or administrative, arising out of this incident;

4. I have already settled the matter amicably and that my family and I will not anymore
pursue any legal action against (name of the respondent);

5. The foregoing statements have been fully read and translated to me in (state the local
dialect) dialect, which I understand and that I fully understood their meaning and
importance;

6. I execute this affidavit to attest to the truth of the foregoing statements and for whatever
legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this ______________,

______________________________, Philippines.

(Name of Affiant)
Affiant
ID Type: ______________
ID No. ________________
Issued on ______________
Issued by ______________

SUBSCRIBED AND SWORN to before me this ___________________, in the

__________________________, Philippines. I further certify that I have personally examined the
herein affiant and I am convinced that he/she executed the same freely and voluntarily and
understood its contents.

Doc. No. _________;

Page No. _________;
Book No. _________;
Series of 2014.