Republic of the Philippines)

_________________)s.s

AFFIDAVIT

I, ____(name)__ _, Filipino, of legal age, single and a resident of ____(address)__ _,

after being sworn to in accordance with law, depose and state:

1. That I am a duly licensed driver with ______________________ which is valid

until ________________.

2. That on ____(date)__ _ at around ____(time)__ _, I was driving a motor vehicle

owned by ____________________and registered 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 parking along__________Street, Sison , Pangasinan to

park the van at the parking area of___________, the aforementioned vehicle
suddenly hit the post and as a result the said vehicle sustained damage at its front
_______;

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 the
vehicle.

IN WITNESS WHEREOF,I have hereunto set my hand this____ day of

___________2019 at Angeles City, Philippines.

_______________________
AFFIANT

ACKNOWLEDGEMENT

SUBSCRIBED AND SWORN TO before me, this ___ day of ______ 2019 at
Angeles City, Pampanga.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2019