Republic of the Philippines )

__________________ ) S. S.
__________________ )

AFFIDAVIT

I, PEON, of legal age, Filipino, married, and a resident of ________________after

having been duly sworn in accordance with law, hereby depose and state:

1. That I am a duly licensed driver with Driver's License No. ____________,

which is valid until November 4, 2021;

2. That I personally own a motor vehicle registered in my name which is more

particularly described as follows:

Make: Toyota Motor No.:

Series: Hi Ace Commuter Chassis No.:
Body Type: Van Plate No.: --
Year Model: 2017 MV File No.:

3. That on August 27, 2017 at around six (6) o’ clock in the evening while I was
slowly driving along the National Highway in front of the ____________ a fast
moving vehicle was overtaking in a reckless manner to my left, in order to
prevent collision with my left portion, I swerved a little to my right and suddenly
hit the traffic sign post for the road repair along the National Highway, and as
a result the said vehicle sustained damage at its right front side;

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 our hands this _______________

at Maramag, Bukidnon, Philippines.

PEON
Affiant

SUBSCRIBED AND SWORN to before me, this __________________, by

____________, who exhibited to me his Driver’s License ID No. _____________ as his
Competent Evidence of Identity (CEI) in accordance with the 2004 Rules on Notarial
Practice. I HEREBY CERTIFY THAT HE UNDERSTOOD THE CONTENTS OF THIS
AFFIDAVIT AND THAT THE SAME IS TRUE AND CORRECT ACCORDING TO HIS OWN
KNOWLEDGE AND BASED ON AUTHENTIC RECORDS.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2017.