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AFFIDAVIT

I, AUGISTINO R. NEGRO, of legal age, married, Filipino and a resident of


_____________________, Cebu, after having been duly sworn in accordance with law,
hereby depose and say:

1. THAT I am an owner of a Motor Vehicle covered by a Certificate of Registration


No. 303544065 (attached as Annex “A”) with the following description below:

a. Make: Suzuki
b. Series: Swift 1.2 AT
c. MV File No.: 0701-00000630850
d. Plate No.: GOD 916

2. THAT I secured a Third Party Liability (TPL) Insurance Policy from


Commonwealth Insurance Company with Motor Policy No. PC1461452
(attached as Annex “B”) to cover the motor vehicle above;

3. THAT on ___date___, while I was backing my motor vehicle from my house, I


accidentally hit another car and damaged the front part of my motor vehicle.
Attached as Annex “C” are photos of my motor vehicle with the dents, scratches
and other damages caused by the accident;

4. That I am executing this affidavit to file a claim against my insurance policy and
for other legal purposes.

AFFIANT SAYETH NAUGHT

IN WITNESS HERETO, I affix my signature below this ___ day of ____ 2018 in
the __________________, Philippines.

AUGISTINO R. NEGRO
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this ____ day of _______ 2018 in the
_________________, Philippines; affiant presented to me her competent proof of identity
ID No.: ____________ issued at _________________ on ___________________.

NOTARY PUBLIC
Doc No. ___
Page No. ____
Book No. ____
Series of 2018

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