Republic of the Philippines)

City of Davao.)s.s.

AFFIDAVIT

I, _____________________, of legal age, Filipino, single and a

resident of ____________________________, after having been duly
sworn to in accordance with law, do hereby depose and say THAT:

1. I am a duly licensed driver with Driver's License No.

__________________, which is valid until ___________;

2. On May 18, 2019, at around 7:30 in the evening, I was

driving a motor vehicle owned and registered in my name
which is more particularly described as follows:

Make: Motor No.:

Series: Chassis No.:
Body Type: Plate No.:
Year Model: MVRR No.:

3. While I was driving along the highway street of Ma-a, the

aforementioned vehicle suddenly hit a dog and as a result the
said vehicle sustained damage at its bottom-front side;

4. I am executing this Affidavit to attest to the truth of the

forgoing and in support of the claim against the insurer for the
repair of the damage caused to my vehicle.

IN WITNESS WHEREOF, I have hereunto set/affixed my

signature this May 21, 2019 at Davao City, Philippines.

_______________________________
Affiant
Driver’s License No. ________
Issued on __________ at Davao City, Philippines

SUBSCRIBED AND SWORN TO before me this _______________

at ___________________________, Philippines.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2019