Republic of the Philippines)

City of San Carlos ) s.s.

AFFIDAVIT

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

_______________________, after having been duly sworn to in accordance with law do hereby
depose and state:

1. That I am in the pedestrian who was accidentally hit by Michael Cruz sometime on
November 24, 2013 at around 8:30 in the evening;

2. That due to the said accident, I was sustained injuries and was confined at
__________________;

3. That Michael Cruz has paid all my hospital bills and I am exonerating him from any
civil and criminal liability whatsoever;

4. That I am no longer filing any case against Michael Cruz;

5. That I am executing this affidavit to attest to the truth of the foregoing statement and
for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I hereby affix my signature this 29 th day of November 2013 at

San Carlos City.

JUAN MIGUEL DELA CRUZ

Affiant
_________________________

SUBSCRIBED AND SWORN to before me in the City of San Carlos, this ___ day of
November 2013 by the affiant, who has satisfactorily proven to me his identity and that he is the
same person who personally signed before me the foregoing statement and acknowledged to
me that he executed the same.

Doc. No. ______;

Page No. _____;
Book No. _____;
Series of 2013;