REPUBLIC OF THE PHILIPPINES)

CITY OF XXX . . . . . . . . . . .)S.S.

X- - - - - - - - - - - - - - - - - - - - X

AFFIDAVIT OF CLAIM

I, XXXX of legal age, Filipino, and a resident of XXXX XXX, after having been duly sworn to
in accordance with law, do hereby depose and state:

That I am the registered owner of a certain one unit motor vehicle, particularly described as
follows:
Make :
Chassis No. :
Series :
Model :
Plate No. :
C.R. No. :
O.R. No. : -0

That the aforementioned motor vehicle was borrowed by my friend XXX, and it was brought to
XXX,

That the said motorcycle incurred un estimated damages on its front fork shock, headlight, left
and right signal lights, rim, etc.;

That I am waiving my rights to claim whatever benefits that could extend to my damaged
motorcycle.

That I am executing this affidavit to attest to the truth of the foregoing statements, and for
whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my signature this _____ day of

________________, at _______________, Philippines.

XXX
Affiant
 SUBSCRIBED AND SWORN to before me this ________ day of _______________ 2009 at
________________, Philippines.