REPUBLIC OF THE PHILIPPINES )

PROVINCE OF )S.S
MUNICIPALITY OF )
x---------------------------------------------------------x

AFFIDAVIT OF UNDERTAKING

I, __________________, of legal age, married, Filipino citizen and resident of

Purok 1, Barangay ______________, Camarines ____________, after having been duly
sworn to in accordance with law, hereby depose and say:

1. That I am the authorized driver of an ambulance owned by LGU,

____________, Camarines and as such, I am a holder of Professional Driver’s
License No. E01-75-003195 issued by the LTO, Daet, Camarines Norte;
2. That sometime on November 27, 2015, while I was driving the said ambulance
in front of the __________________, it was involved in a vehicular accident
with a motorcycle;
3. That as a result of that accident, my driver’s license was confiscated by members
of PNP;
4. That I executed this affidavit in good faith to request from the Chief
______________or any person acting in his behalf, to release the said driver’s
license to my custody pending resolution of the case, if there is any;
5. That I hereby undertake to present and/or surrender the said driver’s license
whenever it is required by the court or by the police authorities for proper
identification/disposition or for other purposes relative to the case;
6. That all the statements above are true and correct to the best of my knowledge
and belief.

IN WITNESS WHEREOF, I have hereunto set my hand this 10th day of

December 2015 at __________________.

__________________
Affiant

SUBSCRIBED AND SWORN to before me this 10th day of December 2015 at

Labo, Camarines Norte, affiant exhibited to me his VIN ID #

Doc. No._____________ NOTARY PUBLIC

Page No._____________
Book No.____________
Series of 2015.