REPUBLIC OF THE PHILIPPINES )

CITY OF SAN FERNANDO PAMPANGA ) S.S

DRIVER’S AFFIDAVIT

That I of legal age, Filipino, married and with postal address at Gerona, Tarlac with
driver license number after having been duly sworn to in accordance with law, do hereby
depose and say;

That I am the authorized driver of the vehicle described as follows:

Make & Type :

Plate No. :
Motor No. :
Serial No. :

That last ________________________, at about ____________ in

the_______________While I was driving
along________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
___________________________________________________________________.

That I am executing this affidavit to attest to the foregoing facts for Insurance claim
to Standard Insurance Co., Inc.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _______ day of

_______________ at City of San Fernando, Pampanga.

Affiant

SUBSCRIBED AND SWORN TO before me this _______ day of _____________,

at City of San Fernando, Pampanga.

Notary Public
Doc. No.________
Page No.________
Book No.________
Series of 2018