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

SUBSCRIBED AND SWORN to before me this _______day of _____________, 20___ at

________________, Affiant exhibiting to me his/her _____________________________ as her
competent proof of identity issued at _____________ on _____________________.

NOTARY PUBLIC

Doc. No. _______

Page No. _______
Book No._______
Series of _______