Republic of the Philippines)

Province of_________________) S.S.

City/Municipality of___________)
x-----------------------x

AFFIDAVIT

I,________________, Filipino, of legal age,(single / married / widow),and

a resident of__________, Philippines, after being sworn to in accordance with
law, depose and state:

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

covered by DLR No.___________, which is valid until___________.

2. That on___________, at around_______, 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. That while I was slowly backing out of the driveway along __________
Street, ____________,to park my car at the parking area of___________,
the aforementioned vehicle suddenly hit the post of the building from
where I was backing out and as a result the said vehicle sustained
damage at its __________;

4. That 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 my hand this ___________

in ___________, Philippines.

AFFIANT

SUBSCRIBED AND SWORN to before me this _______day of

_____________, 20___ at ________________, Affiant exhibiting to me his/her
_____________________________ as her competent proof of identity issued at
_____________ on _____________________.

NOTARY PUBLIC

Doc. No. _______

Page No. _______
Book No._______
Series of _______