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Affidavit of Desistance I, - , Filipino, Single, and Resident of

The affidavit states that the mother of an injured child no longer wishes to pursue criminal or civil prosecution for a bumping accident involving a vehicle. All medical expenses have been settled and the mother releases those involved from any liability and waives rights to take action related to the case.

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Jessa Marie Landero
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21 views

Affidavit of Desistance I, - , Filipino, Single, and Resident of

The affidavit states that the mother of an injured child no longer wishes to pursue criminal or civil prosecution for a bumping accident involving a vehicle. All medical expenses have been settled and the mother releases those involved from any liability and waives rights to take action related to the case.

Uploaded by

Jessa Marie Landero
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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REPUBLIC OF THE PHILIPPINES)

CITY OF BACOLOD ) S. S.

AFFIDAVIT OF DESISTANCE

I, ________________, Filipino, single, and resident of


_________________________________, Negros Occidental, after having been
duly sworn in accordance with law, depose and state THAT:

1. I am the mother of the victim or injured 3-year child caused by a bumping


accident last ____________ involving a ______________with plate
number ___________ registered under the name of __________________

2. That I am no longer interested in the prosecution of said case both criminal


and civil considering that the all the medical expenses are already settled
for the medication of my child;

3. I hereby release _________________ and her son


_________________from any criminal and civil liabilities and waive any
right of action against the aforementioned in connection with the above
case;

4. I fully understand the legal consequences of this Affidavit of Desistance.

5. I am executing this affidavit to attest the truth of the foregoing facts and for the
purpose of claiming of Insurance and for whatever legal purposes it may serve
best.

IN WITNESS WHEREOF, I have hereunto set our hands this 28th day of January
2022 at Bacolod City, Negros Occidental, Philippines.

_____________ With Conformity:


Affiant _______________
UMID ID with ID No.
_____________________

SUBSCRIBED AND SWORN to before me this ____________ day of January


+_____________________, Negros Occidental, Philippines by affiant who has
satisfactorily proven to me her identity through her _________________________.

Doc. No.
Page No.
Book. No.
Series of

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