Republic of the Philippines)

Province of ___________) s.s.

City of ______________.)

AFFIDAVIT

I, JUAN DELA CRUZ, of legal age, Filipino, single and a resident of

_________________________, after having been duly sworn to in
accordance with law, do hereby depose and say THAT:

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

_________, which is valid until___________;

2. On August 16, 2017, at around 8:30 oclock in the evening, 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. While I was driving along the highway street of

______________, the aforementioned vehicle suddenly hit a
dog and as a result the said vehicle sustained damage at its
______________________________________;

4. 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/affixed my

signature this ______________ at ____________________,
Philippines.

JUAN DELA CRUZ

Affiant
Drivers License No. 123-56-025856
Issued by: LTO

SUBSCRIBED AND SWORN TO before me this

_______________ at ___________________________, Philippines.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2017