AFFIDAVIT

REPUBLIC OF THE PHILIPPINES]

Valenzuela City ]s.s.



I, _________________, of legal age, Filipino, and a resident of 30313 C. Molina St. Blk. 6 Viente
Reales, Valenzuela City after having been sworn to in accordance with law hereby depose and say:


1. That I am the owner of a certain Vehicle which is more particularly describe as
follows:

MAKE/ TYPE:
MOTOR No.:
SERIAL No.:
Model:
MV FILE:
PLATE No.:

2. That last night May 25, 2014 at around 9:00pm I was about to park the said vehicle
at the front of a convenient store (MINISTOP) in Bangkal, McArthur Highway when
suddenly a rushing motor vehicle hit the back of my vehicle then run away.

3. That I am executing this affidavit to attest to the truth and veracity of all the
foregoing facts and to inform the proper authorities concerned of Insurance
Company and for whatever legal interest and purposes it may serve.

AFFIANT FURTHER SAVETH NAUGHT.
IN WITNESS HEREOF, I have affixed my signature this __ day of May, 2014 at Valenzuela City.

Roman P. De Guzman
Affiant

SUBSCRIBED AND SWORN to before me this _____day of May, 2014 at Valenzuela City.
.



NOTARY PUBLIC


Doc. No.______
Page No.______
Book No.______
Series of 2014