REPUBLIC OF THE PHILIPPINES)

) S.S.

AFFIDAVIT

I, ____________________________, of legal age, Filipino, single and a resident of

____________________________________________, after having been duly sworn to in accordance
with law, hereby depose and say: That –

1. I am a duly licensed driver with Driver’s License No. ___________________, which is valid until
________________________;

2. On ______________________, at around _________________ in the morning, I was driving a

motor vehicle owned and registered under _____________________________. which is more
particularly described as follows:

Make : Year Model:

Engine No : Plate No.:
MV File No. : Series:

3. On the said date and time, I parked the above-mentioned vehicle in _____________________ at
_________________________________.

4. When I came back after _____________ hour, I discovered that the right side of the vehicle near
the headlight was damaged, with dent and scratches;

5. I have no knowledge of facts indicating as to who was responsible for the said damages;

6. I attest to the truthfulness of the above facts and I am executing this affidavit in order to recover
insurance proceeds and for other purposes as it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ______________________, at

______________________, Philippines.

____________________________
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of _____________________ at Municipality

of ___________________________, Philippines, affiant exhibiting to me his __________________ ID
with No. _______________ at _______________________.

NOTARY PUBLIC

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2019.