REPUBLIC OF THE PHILIPPINES )

PROVINCE/CITY OF ______________ ) SS.

AFFIDAVIT

I, _____________________________, of legal age, Filipino citizen, and a resident of

___________________________________________________, after having been duly sworn to in
accordance with law, hereby voluntarily depose and say:

1. That I am one of the passengers of that public utility van particularly identified as a
Nissan Urvan having Plate No. EVU-964 that figured in an accident sometime in the
afternoon of April 11, 2017 while we were traveling along the national highway in
Sooc, Lupi, Camarines Sur heading to Naga City;

2. That as a result of the said accident, I, together with the other passengers of the
van, sustained physical injuries necessitating treatment and medication;

3. That I fully understand and accept that said unfortunate event is purely accidental
in nature and was not attended by negligence on the part of the driver or owner;

4. That the owner of the motor vehicle, ENRICO A. VELASCO, had likewise extended
to my full satisfaction all the assistance that he could provide to cover for the
expenses incurred owing to our treatment and medication;

5. That in view of the foregoing, I do hereby freely, voluntarily, and absolutely

release, clear, absolve, and discharge the said ENRICO A. VELASCO and his
driver JOSEPH B. DOLLERO from any action, cause of action, sum of money,
liability, damages, claims and demands whatsoever, which in law or in equity I
have, or which I, my heirs, insurer, successors and assigns hereafter may have
upon or by reason of the injuries sustained by me arising from the said incident;

6. That I further warrant that I will institute no further action, civil, criminal or
otherwise, against the said ENRICO A. VELASCO and/or his driver arising from, by
reason of, or in connection with, the aforementioned vehicular accident. I also
manifest that the said payment/settlement made by the owner shall not be taken
by me, my heirs, my insurer or assigns, as a confession and/or admission of
liability on his part or of his driver in connection with the aforementioned accident.

7. That I have fully read or caused to be interpreted, and understood the contents of
this affidavit, that the same reflects my true intention, and that I am also fully
aware of the legal effects of executing and signing of the same.

IN WITNESS WHEREOF, I have hereunto set my hand this __________________, in

_______________________________.

_____________________________
Affiant

SUBSCRIBED AND SWORN to before me, this __________________, in

______________________ _____________________, by the above-named affiant who presented
to me his _______________________ ________________________ as competent evidence of his
identity.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2017.