REPUBLIC OF THE PHILIPPINES )

Valenzuela City, Metro Manila ) S.S.

AFFIDAVIT

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

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

1. That I am a duly licensed driver with Driver's License No._____________covered by

DLR No.___________, which is valid until___________.

2. That on___________, at around_______, I was driving a motor vehicle owned and

registered in my name which is more particularly described as follows:

Make: Motor No.:

Series: Chassis No.:
Body Type: Plate No.:
Year Model: MVRR No.:

3. That while I was slowly backing out of the driveway along __________ Street,
____________,to park my car at the parking area of___________, the aforementioned vehicle
suddenly hit the post of the building from where I was backing out and as a result the said
vehicle sustained damage at its __________;

4. That I am executing this Affidavit to attest to the truth of the forgoing and in support
of the claim against the insurer for the repair of the damage caused to my vehicle.

IN WITNESS WHEREOF,I have hereunto set my hand this ___________ in___________,

Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this _____ day of __________ 2010. Affiant
exhibited to me

Doc. No.
Page No.
Book No.
Series of 2010.