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___________ ) S.S.


I, _________________, of legal age, single, Filipino with postal
address at ______________________ after having been sworn in
accordance with the law hereby depose and state that:

1. I am a driver of a motor vehicle with plate no. _______ which figured
in an accident;

2. Sometime last JULY 25, 2012 approximately Twelve olock in the
afternoon, I was a party to an accident whereby I accidently
sideswiped a person in the name of ____________ while I was trying
to avoid a collision between a bicycle;

3. Because of such incident, the vehicle that I was driving was
impounded by the authorities;

4. I hereby undertake to produce said vehicle upon request of the
authorities if such will be needed for further proceedings or

5. This affidavit is being executed to support my request for the release
of the impounded vehicle;

6. I am executing this undertaking to attest to the truth of the

IN WITNESS WHEREFOR, I have hereunto set my hands this ______ day of
_______________, 2012 in Naga City, Philippines.


SUBSCRIBED AND SWORN TO before me this _____ day of ________, 2012
in the City of Naga, Affiant Exhibiting to me his _____________ issued on
December 15, 2011 in Manila, Philippines.

Doc No.
Page No. Notary Public
Book No.
Series of 2012