Republic of the Philippines }

Province of South Cotabato }S.S.

City of Koronadal }
x======================x

AFFIDAVIT OF UNDERTAKING

I, ___________________, of legal age, single, Filipino and a resident of

____________________________, after having been sworn to in accordance
with law, hereby deposes and states that:

1. I am the registered owner and driver of a certain motor vehicle,

more particularly described as follows:

Make : __________
Type of Body : __________
Engine No. : ___________
Serial/Chassis No. : ___________
Plate No. : ___________
Year Model : _____
MV File No. : ___________

2. On ____________, while I was travelling from

___________________, I was caught by a Land Traffic Officer
(LTO) operative at _______________ for violation of travelling with
defective brake light;

3. I hereby undertake that I already repaired the said defects to

comply with the rules and regulations of the Land Transportation
Office (LTO);

4. I make these statements under oath and in good faith in order to

establish the fact that said defect was already repaired;

5. I am executing this affidavit voluntarily to attest to the truth of the

foregoing facts based on personal knowledge and authentic
records and in compliance with the requirements of the Land
Transportation Office for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

______________, in the City of Koronadal, South Cotabato, Philippines.

_______________
Affiant

SUBSCRIBED AND SWORN to before me this ________________ , in

the City of Koronadal, South Cotabato, Philippines with an affiant exhibiting to me
his _______________________ with his photograph appearing thereon
sufficient to establish his identity.

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