REPUBLIC OF THE PHILIPPINES)

BUTUAN CITY…………………………) S.S.

DRIVER’S AFFIDAVIT

I, _____________________________, 39 years old, Filipino, and a resident

of_________________________, duly sworn in accordance with law hereby depose and states:

That I am the owner/driver of one (1) unit ___________ and duly licensed No.
______________________, more particularly described as follows:

MAKE/SERIES :
CHASSIS No . :
ENGINE No. :
PLATE NO. :
Registered owner :

That on ______________________, 2022 at around 1:30 pclock in afternoon, I was

tyravelling from Butuan city going home to beunavista, agusan del norte. Upon reaching on the
Buenavista cometary in front of inc churc, I accidentally hit by anstray stoned caused by the unidentified
UV express van (ehich overtake unexpectedly), causing the totasl damaged of windshield (cracked the
whole winshield.

That I am executing this affidavit to attes the forgoing facts to support the insurance claim, to
the above described vehicle and for any other legal purpose/s this affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ in Makati

City, Metro Manila, Philippines.

____________________
Affiant

 SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant exhibiting to me his/her competent evidence of identity by way
of __________________ issued at ______________ on __________________.

Doc. No. _____;

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