Affidavit in Support of Reckless Imprudence Complaint for Damage to Vehicle

Republic of the Philippines)

Province of )S.S.
City/Municipality of
x------------------x

AFFIDAVIT

I, ,Filipino, of legal age,(single / married / widow),and a resident of , Philippines, after being

sworn in accordance with law, depose and state:

That I am a duly licensed driver with Driver's License No. , which is valid until the year and that I usually drive
a vehicle in bringing my son to school at , which vehicle is specifically described as a with Motor
No. , Chassis No. and with late No. issued by the Land Transportation Office of the City of
Bacolod and is registered in the name of ,with Certificate of Registration No. issued
on and with MVMRR No. dated ;

That on at around PM, when I brought my son to school and when the said vehicle was parked
at , another vehicle, identified as a with Plate No. and in color, stopped
in front of my vehicle to also bring an a student to school;

That after the student who alighted from the said had entered the school gate, the driver of the said ,
recklessly and impudently, tried to make a U-Turn and hit / bumped my vehicle and that when I instantaneously blew my horn, the
driver of the said quickly accelerated and feloniously fled away in the direction going to ;

That as a result of the incident, the I was driving sustained damage in its .

That the said incident was witnessed by many persons, most of whom are also parents of students who were likewise bringing their
children to school, and has been duly documented in the Blotter of the Traffic Division of the .

That upon inquiry with the Security Office of the , it was discovered that the said has been issued a Car
Pass by the school upon application of a certain , a Grade student of , with residence at
.

That I am executing this Affidavit to attest to the truth of the foregoing and in support of charges for"RECKLESS IMPRUDENCE"
against the driver of the said or for whatever other action that may be filed against the driver and/or registered owner
of the said vehicle and in support of claims against the insurer for the repair of the damage caused to the vehicle I was driving.

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

AFFIANT

(JURAT)