REPUBLIC OF THE PHILIPPINES)

__________________________________) S.S.

AFFIDAVIT

I, ____________, of legal age, Filipino and a resident of ____________ after

being sworn in accordance with law, hereby depose and state that –

1. I am the authorized driver of an ________-_________;

2. On 29 January 2022, a Notice of Violation, was generated and

issued by the Metro Bataan Development Authority involving the aforesaid
motor vehicle;

3. I am executing this affidavit to attest that I was driving said motor

vehicle which was referred to in the Notice of Violation with Violation No.
__-------_____;

4. Finally, I am executing this affidavit to attest the truth and veracity

of the foregoing statements and for all legal intents and purposes it may serve;

5. Affiant sayeth naught.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_____________________ at ______

________________________
Affiant

SUBSCRIBED AND SWORN to before me, this _________________ at

_______affiant exhibiting to me his Driver’s License No. ________________ bearing
his photograph and signature as competent evidence of his identity.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2022.