Republic of the Philippines )

Tagum City, Davao del Norte ) s.s.

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

AFFIDAVIT
I, _______________________, Filipino, of legal age, single, and a resident of
_______________________, Philippines, after having been duly sworn to in accordance with law
hereby depose and state that:

I am the authorized driver of _______________________, who is the registered owner of a

certain motor vehicle covered by Certificate of Registration-CR No. _______________________ and
Official Receipt No. _______________________ which is more particularly described as follows:

Make: _______________________;
Series: _______________________;
Fuel: _______________________;
Denomination: _______________________;
Engine no.: _______________________;

Serial/Chassis no.: _______________________;

MV File no.: _______________________;
Plate no.: _______________________

That on a rainy evening of February 16, 2021, while I was driving home traversing
the National Highway of _______________________, I did not notice the deep excavation along the
road fronting the Land Bank of the Philippines. The front part of the car fell on the said
deep excavation which resulted to the damage of the above-described vehicle.

That I execute this affidavit to attest to the truth of the foregoing statements and in
support of my claims for reimbursement from the insurance company.

IN WITNESS WHEREOF, I have hereunto set my hand this 19 th day of February, 2021
at Tagum City, Davao del Norte.

_______________________
Affiant
_______________________

SUBSCRIBED AND SWORN to before me on the same date and place as above.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of ____.