Republic of the Philippines )

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

I, GIRL, of legal age, Filipino, single, and resident of Brgy. PLACE

after having been duly sworn to in accordance with law, hereby depose
and state that:

1. On January 24, 2019, GUY, of legal age, Filipino, a resident of Place,

and my common-law spouse, threatened and inflicted physical
injuries to me by kicking and punching me.

2. He was detained in the Place Municipal Police Station on even date.

3. For his actions and behavior, he could be held liable for violation of
Republic Act No. 9262 or the Anti-Violation on Women and Children
Act.

4. However, to avoid a protracted litigation and to free ourselves from

the unnecessary costs involved therein, I therefore declare and
manifest my absolute lack of interest and permanent desistance from
filing any suit, whether civil or criminal, arising out of this incident.

5. I have already settled the matter amicably and my family and I will
not anymore pursue any legal action against Guy.

6. The foregoing statements have been fully read and translated to me

in Karay-a, which I fully understood their meaning and importance.

7. 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 hand this 25th day

of January, 2019, in PLACE.

GIRL
Affiant

JURAT