REPUBLIC OF THE PHILIPPINES )

) S.S.

AFFIDAVIT OF UNDERTAKING

I, _________________, of legal age, [civil status], Filipino, a resident of

______________________, after being sworn to in accordance with law, hereby depose and
state that:

1. I am a duly licensed driver with [Professional/Non-Professional] Driver’s License No.

______________ issued by the Land Transportation Office, expiring on ____________;

2. Around ____ of __________, I was driving a motor vehicle owned and registered in my
name, which is more particularly described as follows:

Make: Year Model:

Series: Plate No.:
Body Type: C.R. No.:

3. On above given date and time, I was a party to an accident whereby I [details of
accident];

4. Because of such incident, the vehicle that I was driving was impounded by the
authorities;

5. I hereby undertake to produce said vehicle upon request of the authorities if such will
be needed for further proceedings or investigation;

6. I am executing this Affidavit to attest to the truth of the foregoing statements in

support of my request for the release of the above-described impounded vehicle, and
for other legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _________ at _______________.

________________
Affiant

SUBSCRIBED AND SWORN to before me this _________ at _______________, affiant

exhibited to me his ______________________________, as competent evidence of his identity.