Republic of the Philippines)

Province of_________________) S.S.

City/Municipality of___________)
x------------x

AFFIDAVIT
I,____________,Filipino, of legal age,(single / married / widow),and a
resident of__________, Philippines, after being sworn to in accordance with
law, depose and state:

1.That I am a duly licensed driver with Driver's License

No._____________covered by DLR No.___________, which is valid
until___________.

2. That on___________, at around_______, I was driving a motor vehicle

owned and registered in my name which is more particularly described as
follows:

Make____________ Motor No.:____________

Series:__________ Chassis No.:___________
Body Type:___________Plate No.:_____________
Year Model:___________MVRR No.:____________

3. That while I was slowly backing out of the driveway

along__________Street,____________,to park my car at the parking area
of___________, the aforementioned vehicle suddenly hit the post of the
building from where I was backing out and as a result the said vehicle
sustained damage at its __________;

4. That I am executing this Affidavit to attest to the truth of the forgoing and
in support of the claim against the insurer for the repair of the damage
caused to my vehicle

IN WITNESS WHEREOF,I have hereunto set my hand

this___________in___________, Philippines.

AFFIANT

(JURAT)