REPUBLIC OF THE PHILIPPINES)

Province of Capiz
) S.S.
City of Roxas City
)
x------------------x

AFFIDAVIT OF UNDERTAKING
I, __________________, of legal age, Filipino and a resident of
___________________________ after having been duly sworn to in
accordance with law, hereby depose and state:
1 That I am the buyer/new
_____________________,
_____________, Chassis
_________________ in the

owner of a vehicle described as Make:

Plate No. _____________, Engine No.
No. ______________ under CR No.
name of previous owner _____________;

2 That the said vehicle was involved in a vehicular accident on

_________
at
about
__________
in
the
afternoon
at
__________________ as duly reported before the PNP Police Station,
Roxas City, and it is presently in the custody of the PNP Station
Roxas City;
3 That considering that I and my family use the said vehicle for our
family business/personal service purposes, if it will not be released
back to us, it will caused us tremendous losses to our livelihood as well
as damage to the vehicle itself if the same will remain unused;
4 That in the event the said vehicle is returned back in my possession, I
expressly undertake to immediately redeliver the same to the Roxas
City Police Station and to the court (if any case is filed involving said
incident) as they may be required for the final disposition of the
case/vehicular/traffic accident that occurred, and further undertake
that I will shoulder any obligation over the said vehicle while the same
is in my custody;
5 That I attest to the truth of the foregoing facts.
IN WITNESS WHEREOF, I have set my hand this _________ at
Roxas City, Capiz, Philippines.
__________________
Affiant
ID No: _______________
Issued on/at: __________
SUBSCRIBED AND SWORN to before me this _________ at Roxas
City, Capiz, Philippines by affiant who is personally known to me and further
exhibited his competent identification as shown above.