Republic of the Philippines )

City of ____________ )
x------------------------------------------x

DRIVER’S AFFIDAVIT
I, ____________________, of legal age, single, Filipino, and a resident of
_______________________, Philippines, after having been duly sworn in accordance with
law, do hereby depose and say that:

1. On or about 9:00 in the morning of _______________, I was driving a motor

vehicle described as follows:

Make: MV File No.:

Series: Engine No.:
Body type: Chassis No.:
Year/model: C.R. No.:
O.R. No.:

2. Said vehicle is registered in the name of _____________________of

____________, Philippines. Said person is my (insert relationship if affiant is not
the registered owner) . That I was authorized to drive the said vehicle by
_________________________ and I am a holder of a Driver’s License with No.
____________________ duly issued by the Land Transportation Office (LTO)–
_______ District Office;

3. On the above-mentioned date and time, while I was driving said vehicle at
_____________________. (Insert the circumstances surrounding the incident);

4. The extent of the damage is due for assessment by a competent technician; and

5. I have executed this Affidavit to state the aforementioned facts under oath for the
purpose of filing a claim and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

__________________ at ___________, Philippines.

_____________________________
Affiant
ID No. _________

SUBSCRIBED AND SWORN to before me this _______________, at

__________, Philippines. Affiant exhibited to me his competent evidence of identity as
above-indicated.

NOTARY PUBLIC

Doc. No.
Page No.
Book No.
Series of 2021.

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