AFFIDAVIT

I, _____________, of legal age, married, Filipino and residing at

___________________, after having been duly sworn in accordance with law, hereby
depose and state, that:

I am the family driver of Ms. _____________, the registered owner of a Honda

Civic Sedan with plate N0. __________, under CR N0. ___________ of the Land
Transportation Office.

On __________, we went to _______________ to shop and parked the said car in

the mall’s parking area.

At about 2:00 o’clock in the afternoon, after we were through with our shopping, I
noticed that the rear bumper was damaged, presumably caused by a vehicle which was
trying to maneuver in the parking area.

It was a case of a hit and run incident as nobody saw what happened.

I am executing this affidavit for the purpose of attesting to the truthfulness of the
above statements, to inform the insurance company about the incident and for whatever
legal purpose that it may serve.

IN WITNESS WHEREOF, I have hereunto signed this affidavit this

____________________in _________ City.

Affiant

Republic of the Philippines)

)s.s.

SUBSCRIBED AND SWORN TO before me this _____________ in ______

City.

Doc No._____;
Page No._____;
Book No._____;
Series of 20__.