REPUBLIC OF THE PHILIPPINES)

PROVINCE OF )
CITY OF ) S.S

AFFIDAVIT OF UNDERTAKING

I, name, of legal age, Filipino, married, with residence at address after having
been duly sworn to in accordance with law, do hereby depose and say:
1. I am the authorized driver of a motor vehicle with plate no. WEK661 which
figured in an accident last April 8, 2024 at 11:53 a.m. while I was cruising along
the crossing at Azuceña Street and Sampaguita Street in Naga City Subdivision;

2. I was driving along when the vehicle I was driving was already in the middle of
the interception when a vehicle with plate no. decided to traverse going to
Sampaguita Street from Panganiban Drive which caused me to immediately use
my brake but caused a minor scrape on the front bumper of the vehicle I was
driving and scraped the passenger door of the other vehicle;

3. Because of such incident, my driver's license has been confiscated by the Land
Transportation Office (LTO) through the intervention and respondence of the local
Philippine National Police (PNP);

4. I hereby undertake to produce my driver's license and my person upon request of

LTO authorities and other agencies if needed if such will be needed for further
proceedings or investigation;

5. I am executing this affidavit to attest to the truth of the foregoing facts and to
support my request for the release of my driver's license.

IN WITNESS WHEREOF,I hereunto set my hand and affix my signature on this

th
13 day of April, 2024, in Naga City, Camarines Sur.

name
Affiant

SUSCRIBED AND SWORN before to me this 15th day of April, 2024 in address
with an affiant exhibiting to me his with his photograph appearing thereon sufficient to
establish his identity.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2024.