You are on page 1of 1

Republic of the Philippines }

In the _____________ }Ss.

x- - - - - - - - - - - - - - - - -x


I, __________________, of legal age, Filipino, married, and a resident of

Poblacion Antipas, Cotabato, first being sworn to in accordance with law, do
hereby depose and say:

1. That I am the registered owner of a motor vehicle described as follows:

Make: Ford
Body: Pick-up
Denomination: Utility Vehicle
Year: 2014
Engine No.:
Fuel: Diesel
Chassis No.:
Plate No.:

2. That sometime on ______________________ while I was in Kidapawan

City, I just found out that the rear right stoplight of my aforesaid motor
vehicle was damaged;

3. That the said damage may have been caused by a stone or hard material
hitting the said part of the vehicle from an unknown source;

4. That the cause of the damage was not due to my own fault, or any person
acting in my behalf or under my direction, and was not ever intended by me
or my family members and agents;

5. That I am executing this affidavit in good faith in order to attest to the truth
of the foregoing and to apprise the proper authorities concerned for
whatever legal purpose this may best serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 6 th day of

November, 2014 in the City of Davao, Philippines.


SUBSCRIBED AND SWORN TO before me this 6th day of November, 2014

in the City of Davao, Philippines. Affiant exhibited his

Doc. No.;
Page No.;
Book No.;
Series of 2014.