Republic of the Philippines)

________________________
________________________
x----------------------------------x

) S.S
)

AFFIDAVIT

I, _______________, of legal age, Filipino, married and a resident of

____________________ under oath state:
1.

That I am the registered owner/driver of a certain truck

vehicle described as Make/Series: ____________, Plate No.
_____________, Engine No. __________________, Chassis No.
____________________,

C.R.

No.

____________________

registered in my name;
2.

That I was issued a Professional Drivers License No.

___________________________

valid

until

_________________________;
3.

That in the afternoon of __________________ while I was on

my way going to ______________________ driving the said
vehicle, some hard/stone objects from nowhere hit the
front windshield and right side of the window glass of the
vehicle;

4.

That due to said impact, the vehicles front windshield and

its right side of the window glass were broken and
damaged;

5.

That I am executing this affidavit to inform the insurance

entity about such incident as one of the requirements for
insurance claim;

6.

That I attest to truth of the foregoing facts, for all legal

intents and purposes.

IN WITNESS WHEREOF, I hereunto affixed my signature this

______________________ at ______________________________.

___________________________
Affiant
PDL No:
____________________

Valid until:
________________
SUBSCRIBED AND SWORN to before me this _____________________ at
_____________________ by affiant who is personally known to me and further
exhibited his competent identification as shown above.