REPUBLIC OF THE PHILIPPINES)

City of Taguig ) S.S.

x-----------------------x

AFFIDAVIT
I, XXXXXXXXXXXX, Filipino, of legal age, married, and a resident of
XXXXXXXXXXXXXX, after being sworn in accordance with law, depose and state:

That I am a duly licensed driver with Driver's License No. (PLEASE EDIT), issued by the Land
Trasnportation Office, (WHAt branch) which is valid until the year _(PLEASE EDIT);

That I drive a vehicle more particularly described as follows:

Make : XXX
Denomination : XXX
Year/Model : XXXX
Plate No. : XXXX
Color : XXXX
MV File No. : XXX
Engine No. : XXX
Chassis No. : XXX
CR No./Date : XXX
OR No./Date : XXX
Owner’s Name : XXX

That sometime last XXXXXXXX at around XXXX AM/PM, I went to name of place located at
XXXXXpls put addressXXXXX to do my overtime work. Being a Sunday and as is customary, I parked
the above mentioned vehicle in the back portion of the building along WHAT STREET and proceeded to
my office to do my work;

That at around 1:30PM on the same date, after finishing my overtime work, I went back to my
vehicle. However, when I went to the XXXXXXXXXX SIDE, I noticed damage, dents, and scratches on
the said portion of the vehicle;

That I tried to inquire from several individuals present at the area during that time on what or who
might have caused said damage/dents/scratches but to no avail as no one witnessed the incident or could
identify the person and/or vehicle that caused said damage. It is at this juncture that I realized that I was a
victim of hit and run by another vehicle;

That I am executing this Affidavit to attest to the truth of the foregoing and in support for my
insurance claim and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this DATE in PLACE, Philippines.

Name
AFFIANT

SUBSCRIBED AND SWORN to before me, this _____________, by the Affiant who is
personally known to me and who exhibited her Community Tax Certificate No/ID No. .
_____________ issued at/by _____________ on _____________.

NOTARY PUBLIC

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 20____.