Republic of the Philippines)

Province of_________________)S.S.
City/Municipality of___________
x - - - - - - - - - - x
A F F I D A V I T
I, _____________,Filipino, of legal age,(single / married / widow),and a
resident of _____________, Philippines, after being sworn in accordance with law,
depose and state:
That I am a duly licensed driver with Driver's License No.___________, which is
valid until the year________and that I usually drive a vehicle in bringing my son to
school at ____________, which vehicle is specifically described as a
__________with Motor No.____________, Chassis No. ___________and with late
No.___________issued by the Land Transportation Office of the City of Bacolod and
is registered in the nameof____________,with Certificate of Registration
No.____________issued on____________and with MVMRR No.
_____________dated___________;
That on__________at around _______PM, when I brought my son to school and
when the said vehicle was parked at____________, another vehicle, identified as
a____________with Plate No. _____________and_____________ in color,
stopped in front of my vehicle to also bring an a student to school;
That after the student who alighted from the said _____________had entered the
school gate, the driver of the said____________, recklessly and impudently, tried
to make a U-Turn and hit / bumped my vehicle and that when I instantaneously
blew my horn, the driver of the said ___________quickly accelerated and
feloniously fled away in the direction going to____________;
That as a result of the incident, the _____________I was driving sustained damage
in its ____________.
That the said incident was witnessed by many persons, most of whom are also
parents of students who were likewise bringing their children to school, and has
been duly documented in the Blotter of the Traffic Division ofthe ____________.
That upon inquiry with the Security Office of the___________, it was discovered
that the said ____________has been issued a Car Pass by the school upon
application of a certain___________, a Grade________studentof_____________,
with residence at ____________.
That I am executing this Affidavit to attest to the truth of the foregoing and in
support of charges for"RECKLESS IMPRUDENCE" against the driver of the
said____________or for whatever other action that may be filed against the driver
and/or registered owner of the said vehicle and in support of claims against the
insurer for the repairof the damage caused to the vehicle I was driving.
IN WITNESS WHEREOF, I have hereunto set my hand
this____________in_____________, Philippines.
AFFIANT
(JURAT)