Republic of the Philippines)

Province of_________________) S.S.

City/Municipality of__________)

AFFIDAVIT

I, ____________,of legal age, Filipino,(single / married / widow),and a resident

of____________, Philippines, after being sworn in accordance with law, depose and
state:

1. That I am the true and registered owner of a certain motor vehicle, more
particularly described as follows:

_____________
Motor No.:_____________
Chassis No.:_____________
Plate No.:_____________

2. That I am a duly licensed driver with Professional Driver's License No.

_______________, which is valid until ______________.

3. That on _____________, at around _________, I parked the said motor

vehicle at ____________.

4. That after an _____________ later, when I returned to the said vehicle, I

was surprised as I arrived to find the ___________ of my motor vehicle was
stolen and my car vandalized. There were scratches on the front right side of
it, with its paintwork damaged and needs repair.

5. That I am executing this Affidavit to attest to the truth of the foregoing and
in support of my claim on the insurance of the said motor vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this_____________,

the City of ___________, Philippines.

AFFIANT

(JURAT)