Republic of the Philippines )

City of -- ) S.S.

AFFIDAVIT

I, --, of legal age, married to --, and a resident of --, is the

owner of a Toyota Vios with plate number --, herein referred to
as FIRST PARTY;

-and-

That on --, the two above-mentioned vehicles figured in a

vehicular accident at --;

That the FIRST and SECOND PARTIES agreed to the

following, to wit:

1. That the First Party will shoulder the cost of the repairs
for his own car using his insurance with -- with Policy
Number --;

2. That the Second Party will shoulder the cost of the

repairs for his own car at his own expense;

3. That the Second Party will pay the amount of the

Participation Fee upon computation of the First Party’s
Insurance and some other costs related to the said
accident;

4. That the First Party undertakes to present official

receipts for any and all expenses/costs to be recovered
from the Second Party;

5. That the First Party will no longer file any criminal

and/or civil case regarding the accident against the
Second Party and releases the latter from any other
claims;

6. That the First Party and the Second Party amicably

settled the instant case.

FURTHER AFFIANTS SAYETH NONE.

IN WITNESS WHEREOF, we have hereunto set our

hands this -- day of -- 2023, in --.
 -- --
Affiant Affiant

--
Witness

SUBSCRIBED AND SWORN TO before me this -- day of --

2023, in --, affiants exhibiting their valid Government-issued
ID for identification.