REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ORIENTAL MINDORO ) S. S.

CITY OF CALAPAN )

AFFIDAVIT

I, ____________, legal age, widow and a resident of ____________, Philippines,

after having been duly sworn to in accordance with law, do hereby depose and state
the following:

1. That I am the (widow/widower) of ____________;

2. That my (husband/wife) died on_____________ because of _____________

injuries sustained in a vehicular accident as per the results of the autopsy
conducted by Dr.____________;

3. That per investigation of the _____________ Police Station, my

(husband/wife) died as a result of a vehicular accident at ____________
when while he was_____________, he was bumped / hit by a truck coming
from the opposite direction;

4. That my husband was a duly licensed driver at the time of the incident and
was carrying Driver's License No. ____________ and was riding on a
_____________, ____________ in color and with Plate No. ________ owned
by _____________ with Certificate of Registration No. _____________;

5. That I am executing this affidavit to attest to the truth of the foregoing and
for whatever legal purposes that this statement may serve.

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

in the City of_____________, Philippines.

AFFIANT

(JURAT)