REPUBLIC OF THE PHILIPPINES)

QUEZON CITY )S.S.

AFFIDAVIT OF PAYMENT
(WITH ACKNOWLEDGMENT OF RECEIPT OF PAYMENT)

I, ___________________, of legal age, single,

and with address at __________________,
______________________________, Quezon City, Metro
Manila, Philippines, under oath, state that:

1.On ________________, 2016, while driving my

vehicle, a Fortuner (Year) Model with Plate No.
___________, covered by Certificate of Registration
No. ______________ and Official Receipt No.
__________________ along ______________ heading to
________________, I encountered a vehicular
accident with a __(insert car model)___, with Plate
No. _____________, driven by a certain (insert name
of the driver);

2.Said vehicular collision was reduced into a Police

Report before the __________________ Police Station
located in ____________________;

3.During the discussions and negotiation between me

and _________________, we have agreed that I shall
pay him the amount of _(INSERT THE AMOUNT IN WORDS)
(P FIGURES), representing the value of his
participation fee (and other fees, if any) of his
vehicles insurance with (insert insurer);

4.Complying with the said agreement, on

_______________, 2016, I paid him the said amount
through (insert payment method) as final and full
settlement of my liability with __________________
arising from the said incident;
5._____________________ acknowledged and confirm of
the receipt of such payment through _______________
on the same date;

6.In view of the said settlement, I am hereby release

from any claims, damages, costs, expenses, demands,
suits, obligations, liabilities and/or legal fees,
directly or indirectly relating to the vehicular
collision described above;
7.I am executing this Affidavit of Payment to attest
to the truth and veracity of the foregoing facts
and for whatever legal purposes it may serve.

IN WITNESS WHEREOF, I hereunto affix my

signature this ____th of November, 2016 at Quezon
City, Metro Manila, Philippines.

________________________

Affiant
____(insert ID details)_____

IN CONFORMITY:

_________________________
(Name of Payee)
(Insert ID Details)

ACKNOWLEDGMENT

REPUBLIC OF THE PHILIPPINES)

QUEZON CITY ) S.S.

BEFORE ME, a Notary Public for and in Quezon

City this _____ day of November 2016, personally
came and appeared ________________________ and
______________________ after exhibiting their
_________________ and ____________________,
respectively, all known to me to be the same
persons who executed the foregoing AFFIDAVIT OF
PAYMENT WITH ACKNOWLEDGMENT OF RECEIPT OF PAYMENT
and acknowledged to me as their own free and
voluntary act and deed.
I further that this document consists of THREE
(3) PAGES signed by the parties and their
instrumental witnesses on the left margin of page
one and two and above their respective printed
names on the upper portion of page two three
thereof.
IN WITNESS WHEREOF, I have hereunto signed and
affixed our notarial seal this _____ day of
November 2016 in the Quezon City Philippines,
Philippines.

Doc. No. _______

Page No. _______
Book No. _______
Series of 2016.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2016.