Republic of the Philippines)

Legazpi City )s.s.

x---------------------------------------x

AFFIDAVIT OF CLAIM
I, ____________________, of legal age, Filipino citizen, (civil status), with address at
_____________________________________________-, after having been duly sworn to in
accordance with law, do hereby depose and state:

1. I am the owner of a (color and unit of vehicle), more particularly described as

follows, to wit:

Make & Body Type : _______________

Engine No. : _______________
Chassis No. : _______________
Plate No. : _______________

2.That on __________________, state the circumstances surrounding the

damage/injury to the car/vehicle.

3. That the said incident was merely an accident without fault of anybody.

4. I am executing this affidavit to attest to the truth and veracity of the foregoing
facts and for (state specific purpose for the affidavit), and for whatever legal purpose this
may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of

__________________ at Legazpi City, Philippines.

________________________________
Affiant
ID No. ______________
Issued by: _____________________
SUBSCRIBED AND SWORN TO before me this ___ day of ___________ in Legazpi City.
Affiant exhibited to me his/her Identification Card indicated below his/her name bearing
his/her photograph and genuine signature as competent proof of identity pursuant to 2004
Rules on Notarial Practice.
Doc. No. ____;
Page No. ____;
Book No. ____;
Series of 20___.