REPUBLIC OF THE PHILIPPINES)

) SS.

AFFIDAVIT OF ACCEPTANCE AND RESPONSIBILITY FOR CAUSING DAMAGE/S

I, _________________ Filipino, of legal age, with address at ________________________

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

1. That I am a duly licensed driver with Driver’s License No. ___________ which is valid until
________________.

2. That on ______________, at around _________, I was driving a motor vehicle particularly described as
follows:

OR No.: _____________________________
CR No.: _____________________________
Make: _____________________________
Chassis No.: _____________________________
Plate No.: _____________________________
Model: _____________________________
Motor No.: _____________________________

3. That I bumped the vehicle ______________ me when I _______________ on ____________ at

__________________, damaging the ______________________. The vehicle is particularly described as
follows:

OR No.: _____________________________
CR No.: _____________________________
Make: _____________________________
Chassis No.: _____________________________
Plate No.: _____________________________
Model: _____________________________
Motor No.: _____________________________

Driver’s Name: _____________________________

Address: _____________________________
Contact No: _____________________________

4. That I will shoulder all the expenses needed for the repair of the aforementioned damage/s.

5. That in a breach or non-fulfilment of paying the damages, this acknowledgement will be the basis for any
actions or legal proceedings.

IN WITNESS WHEREOF, I hereby affix my signature this ____ day of ____________ in ___________ City.

_________________________________ ________________________________
Signature over Printed Name of Witness Signature over Printed Name of Affiant

SUBSCRIBED AND SWORN to before me, a Notary Public, this ________________________ at

_____________ City, exhibited to me the following:

Name Identification Number Valid Until Place Issued

1.
2.

Doc. No. :____

Page No. :____
Book No. :____
Series of 2019