Republic of the Philippines

)
) S.S.
x-----------------------x

AFFIDAVIT OF UNDERTAKING

I, NAME, of legal age, (civil status), and a resident of (residence), after having been duly
sworn to in accordance with law, hereby depose and state that:

1. I am the registered owner of a motor vehicle covered by Certificate of Registration No.

________________ issued by the Land Transportation Office (LTO), more particularly
described as follows:

Make:
Type:
Motor No.:
Chassis No.:
MV File No.:
Plate No.:

2.

3. By this undertaking, I hereby assume full responsibility against claims of third person
involving said motor vehicle, and that I will hold the Land Transportation Office (LTO)
absolutely free and harmless from any and all liabilities connected to and / or arising
therefrom;

4. This affidavit is executed to attest to the truth of the forgoing facts and circumstances
and for whatever legal purposes this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of __________ at
Iloilo, Philippines.

NAME
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of ____________ at Iloilo,

Philippines. Affiant exhibited to me (his/her) (competent evidence of identity) issued by
(issuing agency) containing (his/her) picture and signature.