Republic of the Philippines )

Quezon City ) S.S.

x--------------------------x

AFFIDAVIT

I, __________________ of legal age, Filipino citizen, single/married and presently

residing at _____________________________________________, after having been duly
sworn to in accordance with law, do hereby depose and say:

1. That I am the biological sister of ______________________ who died on _________________

in_______________________________ because of____________________________________
(head injuries sustained in a vehicular accident as per autopsy result conducted by Dr. Lito R.
Santossample cause of death lang to, ask her for the cause of death); Attached herewith is my
birth certificate as Annex A, my brothers birth certificate and death certificate attached hereto
as Annex B and Annex C respectively;

2. That my brother is married to _______________________, who is in Taiwan now, attached

hereto is their marriage contract as Annex D;

3. That my brother is an owner of a motorvehicle with plate no._______________ issued by

________________;

4. That I am executing this affidavit in support of my request to secure the OR/CR of the said
motovehicle under my brothers name from Toyota Philippines located
at____________________

5. That I am further executing this affidavit to attest to the truth of the foregoing, and for whatever
legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 6th day of October 2013 at
Quezon City, Philippines.

___________________
Affiant

SUBSCRIBED AND SWORN to before me this ______ of _______________ in the

City of Quezon, Philippines, affiant exhibiting to me her competent evidence of identity by way
of _________________________ issued at __________________ on _________________.

Doc No. : _____

Page No.: ______
Book No.: ______
Series of 2013 Notary Public