Republic of the Philippines)

City of Cebu..) S.S.

AFFIDAVIT

I, _________________________., Filipino, of legal age, married and a

resident of Cebu City, Philippines, after being duly sworn to in accordance
with law, hereby deposes and state:

1. That I am a duly licensed driver with Driver's License issued by the

Land Transportation Office, Cebu City, which is valid until
___________________.

2. That on _____________________, at around 12 noon, I was driving a

motor vehicle owned and registered in my name which is more
particularly described as follows:

MAKE : MV. FILE NO. :

SERIES : CHASSIS NO. :
TYPE OF BODY : PLATE NO. :
PISTON DISPLACEMENT: NO. OF CYLINDERS :
DENOMINATION : C.R. NO. :
ENGINE No. : FUEL :

3. That I park the aforementioned vehicle in the front parking area of

_______________________, Cebu City as I will claim my
___________________________ in aforementioned office;

4. That around _______________ of the same day, as I have already

claim the __________________, I went to my vehicle where I parked
the same, and gave a moving out signal to the other vehicle
described as ____________________ which was parked along the road
perpendicularly in my parking location;

5. That the said _______________ upon seeing such signal, thereafter

moves forward, thus, believing that said vehicle has giving me way
to move out, I then change to revert gear, but all of a sudden to my
surprise, the herein vehicle suddenly reverses its gear car as a
result of which there was a minor scratch of my vehicle in view of
such collision;

6. That this incident was reported to the Cebu City Traffic Operations
Management (CITOM) Office and investigation was conducted
therein;

7. That my Drivers License as well as that of the other motor

vehicles drivers license were confiscated by the CITOM personnel
by virtue of such incident;

8. That until now, there has been no action for any settlement coming
from the other party who had caused damage to my vehicle;

9. That I am no longer interested to file a case against the owner of

such vehicle;
 10. That I wanted to claim my Drivers License which is now in the
custody of CITOM Office, however, I was directed to execute this
Affidavit prior to its release;

11. That I am executing this Affidavit to attest to the truth of the

forgoing facts, in order to claim my Drivers License and for
whatever legal purpose this may serve best.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_____________________ at Cebu City, Philippines.

_____________________.
Affiant
ID No. _____________________
Issued at: Cebu City
Issued on: _________________

SUBSCRIBED AND SWORN to before me on the above place and

date. Affiant exhibited to me his government issued identification card as
shown above below his name.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2017.

ATTY. LECEL R. LLAMEDO

NOTARY PUBLIC for the CITY of CEBU
COMMISSION EXPIRES ON DECEMBER 31, 2013
NOTARIAL COMMISSION NO. 075-10
ROLL NO. 57485
IBP NO. 901880-01/02/2013-Cebu City
PTR NO. 141136-01/03/2013-Cebu City
MCLE Compliance No. IV - 0000725; November 10, 2010
City Attorneys Office, Cebu City Hall; Tel. No. (032) 239-