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                              DOMNULE PRESEDINTE,
   Subsemnatul(a) ………….., domiciliat(a) in …………… inculpat(a), parte vatamata, parte civila, parte responsabila civilmente, in dosarul penal nr. ………… al acestei instante, in care s-a pronuntat sentinta penala nr. ……….. din …………
   In baza art. 368 C. proc. pen., declar expres ca RENUNT LA DREPTUL DE A DECLARA APEL impotriva hotararii citate.
   Data depunerii
   …………..
 Semnatura,
 ……….
   DOMNULUI PRESEDINTE AL …………………

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