REPUBLIC OF THE PHILIPPINES)
City of _____________________) S.S.
x-----------------------x
AFFIDAVIT
I, ________________ Filipino, of legal age, single, 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.
_______________ which is valid until ___________________.
2. That I am employed by _____________ as a _______________.
3. That on ________________, at around 8:30 AM, I was driving a
motor vehicle owned and registered in the name of
______________________which is more particularly described as
follows:
Make: Engine No.:
Chassis
Series: No.:
Body Type: Plate No.:
Year Model: MVRR/CR No.:
5. That on the above date and time, I was on my way to
____________.
6. That while I was driving along the __________________, a stone hit
the windshield of the car described above.
7. That the impact of the above incident caused the crack in the
windshield of the car described above.
8. 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 _____________, by
_____________ who exhibited to me his LTO Driver’s License No.
__________ valid until ___________________.
Notary Public
Doc. No. ______;
Page No. ______;
Book No. ______;
Series of ______;
