Republic of the Philippines)

Province of Surigao del Sur)s.s.

Municipality of Tago . . . . .)
X- - - - - - - - - - - - - - - - - - -/

AFFIDAVIT OF UNDERTAKING

I, xxxxxx, of legal age, Filipino, married and a resident of xxxxxxxxxx,

Philippines after having been duly sworn to in accordance with law hereby depose and
say:

1. That on January 26, 2017, at around 7:45 o’clock in the morning, a single
Honda XRM125, colored red, bearing plate number 71947Q, engine number
XRM16E061982, chassis number XRM16061980, registered, owned and
driven by xxxxxxxxx, and my single Suzuki Raider FU150SCD motorcycle,
color black/red, bearing plate number 7944LP, engine number
G4201D936391, chassis number BG41D116388, registered, owned and driven
by me; both motor vehicles had figured in an accident at the National High
Way, in front of King Cooperative Inc. building, Purok JDN, Brgy. Mabua,
Tandag City, Surigao del Sur, which resulted to the injuries suffered by
xxxxxxxxx and his back ride xxxxxxxxxxxxxxxx;

3. That I admit to have been in default on the above-mentioned accident,

therefore, I take this obligation and hereby undertake to reimbursed
xxxxxxxxxxxxxand xxxxxxxxxxxx the amount of PhP30,000.00 as
payment for the expenses incurred for their medication;

4. That by reason of the accident, my motorcycle crashed and fell down in the
pavement as well as the motor vehicle owned by xxxxxxxxxxxxxxx
Meanwhile, I am applying for the release of the proceeds of the insurance of
my vehicle in order to pay my obligation to xxxxxxxxxxxxxxxxxxxx;

5. That in case of failure of my insurance company to release the proceeds of

the insurance of my vehicle, I hereby assure and undertake to pay
xxxxxxxxxxxxxxxxxxxxxx the amount of PhP30,000.00;

6. That I understand that the Affidavit of Desistance they executed was

intended only to facilitate the processing of my insurance; hence, it will not
bar them from filing a case against me, in case of non-payment by the
insurance company;

7. That I am executing this affidavit to attest to the truthfulness of the

foregoing facts and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 17 th day of March

2017 in xxxxxxxxxxxxxxxxx Philippines.

xxxxxxxxxxxxxxxxxxxxxxx
Affiant

SUBSCRIBED AND SWORN TO before me this 17th day of March 2017 at

xxxxxxxxxxxxxxxxxxxxxxxx, Philippines.