Sample Affidavit

AFFIDAVIT OF JOHN DOE

Name: John Doe

Occupation: Mechanic/Owner of John Doe Auto Repair

I, John Doe, swear or affirm:

1. That I am the Owner of John Doe Auto Repair, located in Madison County, Indiana.

2. That on November 21, 2011, Jim Jones (“Mr. Jones”) brought his 2010 Chevy Cruz to my auto repair
shop for an estimate.

3. That Mr. Jones explained to me at that time that he had been in an accident and said that the other
vehicle owner caused it, and that her insurance company would be paying for the repair.

4. That I have estimated the cost of repair to Mr. Jones’ Cruz to be $1,561.00, and that said estimate is
attached as exhibit A.

Further affiant saith not.

I SWEAR OR AFFIRM THAT THE ABOVE AND FOREGOING REPRESENTATIONS ARE TRUE AND CORRECT TO
THE BEST OF MY INFORMATION, KNOWLEDGE, AND BELIEF.

________________

_____________________________________

Date

John Doe

STATE OF INDIANA

COUNTY OF MADISON

I, the undersigned Notary Public, do hereby affirm that John Doe personally appeared before me on the
___ day of December 2011, and signed the above Affidavit as his free and voluntary act and deed.

_____________________________________

Notary Public