Republic of the Philippines)

____________________ )
_____________________)

AFFIDAVIT
I, AAA, of legal age, single, Filipino and a resident of #____________________,
Pangasinan, after having been duly sworn to in accordance with law do hereby
depose and state:
1. That I am the collector at AAA Corporation, a corporation duly existing and
organized in the Philippines with principal office address at
_________________________________;
2. AAA Corporation is the registered owner of motor vehicle, more
particularly described as follows:
Make/Type
Model
Plate No.
Engine No.
Chassis No.

:
:
:
:
:

As evidenced by copy of the Official Receipt/Certificate of Registration

which is attached as Annex A to form an integral part hereof;
3. That the said motor vehicle is assigned to me as service vehicles for
collection purposes of AAA Corporation;
4. That sometime on _____________ at around 2:00 oclock in the afternoon, I
was driving the said motor vehicle along the National Highway at
________________ when I figured in an accident;
5. That at the time of the incident, I am the holder of a drivers license issued
by the Land Transportation Office under Professional Drivers License No.
______________, a copy of which is hereto attached as Annex B to form
an integral part hereof;
6. That the motorcycle sustained damages which are as follows:
PARTS OF THE MOTORCYCLE
STATUS
1. Left Flaring
2. Tail light and Tail Flaring
3. Rear Handle
4. Right Engine Cover
5. Right and Left Hand Cover
6. Front Finders
7. Passenger Right Foot Cover
8. Headlight Cover
9. Right Flaring
10.Rear Finders

Scratch
Broken
Scratch
Broken
Broken
Broken
Broken
Scratch
Broken Lock
Broken

7. The amount of the damages of the motorcycle is still undetermined;

8. That I am executing this affidavit to attest to the truth of the

foregoing statement and for the purposes of claiming insurance
from the insurer/insurance company.

IN WITNESS WHEREOF, I hereby affix my signature this ____________ at

_______________.

__________________
Affiant
License # ____________
Expires on ____________
SUBSCRIBED AND
__________________.

Doc No. ___

Page No. ___
Book No. ___
Series of 2015.

SWORN

to

before

me

this

________________

at