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REPUBLIC OF THE PHILIPPINES)

CITY OF _____________ ) S.S.


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A F F I D AV I T

I,___________________________________, of legal age, Filipino, with residence address


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

1. That I am the authorized driver of ascertain motor vehicle more particularly


described as follows:
Make and Type: __________________________
Motor Number: __________________________
Serial Number: __________________________
Plate Number: __________________________
MV File Number: __________________________

2. That I am a duly licensed driver with LTO Drivers License No.____________ with an
expiry date of _____________ attached hereto as Exhibit A and made an integral
part of this affidavit;

3. That on __________________ at around _______________, a post was suddenly


dropped and hit the motor vehicle at the premises of __________________ which
had caused damage at the _____________________ of the motor vehicle;

4. That there was no other vehicle involved at the time of the incident;

5. That I am voluntary executing this written undertaking to attest the truth of the
foregoing statements for whatever legal purpose (s) it may serve.

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


2013 at the _____________, Philippines.

AURELIO G. DEL ROSARIO


Affiant
SUBSCRIBED AND SWORN to me before this _________________. The affiant
exhibited to me his _______________No. __________ issued on _____________ at
____________.

Notary Public

Doc No._________________
Page No.________________
Book No.________________
Series of _______________
EXHIBIT A