REPUBLIC OF THE PHILIPPINES)

CITY OF ROXAS . . . . . . . . . . . . . . . . .) S.S.

AFFIDAVIT OF UNDERTAKING

I, xxxxxxxx, of legal age, Filipino, widow and with postal address at xxxxxxxxx,
under oath, depose and state:

1. THAT, I am the owner of a Utility Vehicle, herein specifically described as:

MAKE: xxxxxxxxx
MV FILE NO.: xxxxxxxxx
SERIES: xxxxxxxxx
ENGINE NO: xxxxxxxxx
DENOMINATION: TRUCK
YEAR MODEL: xxxxxxxxx
BODY TYPE: ALUMINUM WING VAN TRUCK

2. THAT, said utility vehicle, while being driven by my duly authorized driver,
xxxxxxxxx, figured in an accident last 05 June 2018, thereby causing damage to other
vehicles involved, as shown and evidenced by the PNP Traffic Accident Report. A copy of the
same is herein attached and is made an integral part of this affidavit;

3. THAT, said utility vehicle is presently insured by the xxxxxxxxx Insurance Co.,
Inc,;

4. THAT, however, the damage caused to other vehicles, which is now due for
repair exceeds the amount covered by the insurance policy;

5. THAT, as such, I hereby undertake to pay and settle the excess amount due by
reason of the repairs of the vehicles involved in the accident, as shown by the “estimate”
provided and herein attached;

6. THAT, I am executing this Affidavit to attest to the truthfulness of the

foregoing facts and to use the same for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __________________

at the City of Roxas, Capiz, Philippines.

xxxxxxxxx
Affiant

SUBSCRIBED AND SWORN TO before me, a Notary Public commissioned in and for
the City of Roxas, Province of Capiz, Philippines, this ______________ by the affiant who is
1
personally known to me and that she is the same person who appeared and signed the
foregoing Affidavit in my presence within my jurisdiction, and who avowed to the truth of
its contents under the penalty of law.

Doc. No.: _____;

Page No.: _____;
Book No.:_____;
Series of 2018.