Republic of the Philippines )

City of Makati               ) S.S.

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

AFFIDAVIT 
            I, LIZA S. DELA CRUZ of legal age, Filipino citizen, widow and
presently residing at 3333 M. Ocampo Street, Pio del Pilar, Makati City, after
having been duly sworn to in accordance with law, do hereby depose and say:

1.  That I am the widow of BENITO D. DELA CRUZ who died on July 30, 2013 in
Quezon City because of head injuries sustained in a vehicular accident as per
autopsy result conducted by Dr. Lito R. Santos;

2.  That per investigation of the Quezon City Police Station, my husband

was driving along the northbound lane of EDSA  in front of Camp Aguinaldo in
Quezon City when he was hit/bumped by a truck coming from the opposite
direction; copy of the Traffic Investigation Report is hereto attached as Annex
"A";

3.  That at the time of the incident, my husband was a duly licensed driver carrying
Driver's License No. 123456 and was riding on a Toyota Innova, gray in color
and with Plate No. XYZ-123 owned by me with Certificate of Registration No.
55667788;

4.  That I am executing this affidavit in support of my application for insurance

claim with _____________, to attest to the truth of the foregoing, and for
whatever legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 6th day of

October 2013 at Makati City, Philippines.

                                                                                    LIZA S. DELA CRUZ

                                                                                                Affiant
                                                                                   

            SUBSCRIBED AND SWORN to before me this 6th day of October 2013

in the City of Makati, Philippines, affiant exhibiting to me her competent evidence of
identity by way of Philippine Passport No. 12344 issued at Manila, Philippines
on September 5, 2012.

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Page No.: ______                                           
Book No.: ______                                              
Series of 2013                                                             Notary Public