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I, X, of legal age, Filipino, single, and a resident of Matina, Davao City,

Philippines, after having been duly sworn to in accordance with law, hereby depose
and state that:

1. I am a duly-licensed driver with Non-Professional Driver’s License No.

12345 which is valid until July 30, 2020;

2. On January 1, 2017, at around 2:00 in the morning, I was driving an Isuzu

Crosswind motor vehicle with Plate No. 54321;

3. The motor vehicle is owned and registered in my name;

4. While I was slowly driving along Apple St., coming from Matina and
heading towards M Highway, a Toyota HILUX motor vehicle with Plate No.
9876, was coming from the opposite direction;

5. The Toyota HILUX vehicle is registered and owned by ABC Co.;

6. While the said Toyota HILUX was speeding and traversing our location, it
failed to slow down and hit the left side mirror of our vehicle;

7. As a result, the entire left side mirror was dented;

8. I proceeded to call the attention of the Toyota HILUX driver but he did not
alight from his vehicle to check the damage he has caused and proceeded to
drive away without acknowledging his liability;

9. We proceeded to chase after the TOYOTA HILUX and managed to corner the
vehicle along Y Avenue;

10. Upon confronting the driver, a certain Mr. Anderson who finally alighted
from the said vehicle, I was met with an obviously alarming and hostile

11. This was when we were able to seek the assistance of the traffic enforcers;

12. As a result the above-mentioned occurrence, my LTO Driver’s License was

confiscated by a Police Officer;

13. I hereby undertake upon release of the said Driver’s License, that I will
submit myself to investigation regarding aforesaid vehicular incident,
whenever called upon by the authorities; and

14. I am executing this affidavit to attest to the truth of the foregoing facts and
for the filing of the appropriate criminal charges against Mr. Anderson.

IN WITNESS WHEREOF, I have hereunto set my hand this 11 th of September

2017 at Davao City, Philippines.


SUBSCRIBED AND SWORN to before me this ______, in the City of Davao,

Philippines, affiant having exhibited to me his LTO Driver’s License with number