REPUBLIC OF THE PHILIPPINES )

MANDALUYONG CITY )S.S.

AFFIDAVIT
I, _____________, Filipino, of legal age, single and with address at ______________, after
being duly sworn to in accordance with law, hereby depose and state:

1. That I am a duly licensed driver with Non-Professional Driver’s License Number

__________ which is valid until _____________. A copy of which is hereto attached and
made integral part hereof as Annex “A”;

2. That on 2 October 2019, at around 11:00 A.M., at the corner of ______________, I was
driving the subject vehicle, which I was authorized to drive and which is more particularly
described as follows:

Make:
Series:
Body Type:
MV File No

3. That as I was completing my left turn _____________ in broad daylight, the unknown
driver’s motorcycle, which was speeding off straight towards the south of __________, hit
the subject vehicle on its right side, causing damage to the subject vehicle;

4. That while I was about to park the subject vehicle to discuss with the unknown driver of
the motorcycle, he drove away without acknowledging his liability. Therefore, this is a
case of “hit and run”, that even the plate number of the motorcycle was impossible to be
ascertained;

5. That there were no traffic enforcers at the time and place of the accident;

6. That I am executing this Affidavit to attest to the truth of the foregoing and in support of
the claim against the insurer for the repair of the damage caused to the subject vehicle.

IN WITNESS WHEREOF, I set my hand _____________, in Mandaluyong City

Affiant

SUBSCRIBED AND SWORN to before me, this ____________ in Mandaluyong City, personally
appeared the above-named person, affiant exhibiting to me his Non-Professional __________
which is valid until 25 May 2023, known to me to be the same person who executed the foregoing
instrument and acknowledged to me that the same is his free and voluntary act and deed.

WITNESS MY HAND AND SEAL on the date and at the place first written above,

Doc no. __
Page no. __
Book no. ___
Series of 2018