Republic of the Philippines )

Province of Negros Oriental) S.S.

Municipality of Sibulan)

AFFIDAVIT OF UNDERTAKING

I, MELWAYNE N. DIPUTADO, of legal age, married, Filipino, and a resident of

Poblacion, Sibulan, Negros Oriental, after having been sworn to in accordance with law, do hereby
depose and state that:

1. I am the registered owner of a motor vehicle, which is more particularly described as

follows:

MOTOR NO.: E472426380 MAKE: SUZUKI

CHASSIS NO.: BE4DX603156 TYPE OF BODY: MOTORCYCLE
MV FILE NO.: 0701-00000364978 YEAR MODEL: 2016
C.R NO.: 254151026 SERIES: FW110D

2. That sometime on July 5, 2023, at about 12:20 PM, I was driving the above-described
motor vehicle somewhere Along Western Nautical Highway Brgy. Tampi, San Jose, Negros Oriental
and figured in an accident;

3. That the said motor vehicle is currently in the possession of the police station of
Municipality of San Jose, Province of Negros Oriental;

4. That I need the use of the above-mentioned motor vehicle for personal use;

5. That I hereby undertake to surrender the possession or present the above-described

motor vehicle to any court or government entity upon proper notice;

6. I am executing this affidavit to attest to the truthfulness and veracity of the foregoing
facts.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _____________________ in

Sibulan, Negros Oriental, Philippines.

MELWAYNE N. DIPUTADO
Affiant

SUBSCRIBED AND SWORN to before me, a Notary Public, on ___________________,

for the Municipality of Sibulan and the Province of Negros Oriental, Philippines, MELWAYNE N.
DIPUTADO, who exhibited before me his Pag-ibig ID No. 1210-5746-0288, and WHO SIGNED IN
MY PRESENCE the foregoing document (Affidavit of Undertaking), and who avows under
PENALTY OF LAW to the whole truth of the contents of the same.

Doc No. ___;

Page No. ___;
Book No. ___;
Series of 2023.