REPUBLIC OF THE PHILIPPINES

____________, METRO MANILA )

AFFIDAVIT

That I __________________________________, of legal age and residing

at __________________________________________, after having been duly
sworn to in accordance with law, hereby depose and state;

That, I am the Authorized driver of _____________________ with Plate

Number _______________, Owned by _____________________________. with
office address at Km. 16.2 West Service Rd., SSH, Bicutan Paranaque,

That 0n
___Date____________________________________________________
____Time_______________________________________________________________
_____PLACE____________________________________________________________
___Damages___________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____.

IN WITNESS WHEREOF, I have hereunto set my hands and affixed

my signature this ____________________

_________________________
Affiant

SUBSCRIBED AND SWORN to before me this________________ at

___________________.affiant exhibited to me his drivers License No.
______________________________________

Doc. No. ______

Page No. ______
Book No. ______ Notary Public
Series of 2021