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I, , of legal age, single, Filipino with postal

address at after having been sworn in
accordance with the law hereby depose and state that:

1. I am a driver of a motor vehicle with plate no. which figured

in an accident,

2. Sometime last JULY 25, 2012 approximately Twelve o'glock in the

afternoon, I was a party to an accident whereby I accidently
sideswiped a person in the name of while I was trying
to avoid a collision between a bicycle,

3. Because of such incident, the vehicle that I was driving was

impounded by the authorities,

4. I hereby undertake to produce said vehicle upon request of the

authorities if such will be needed for further proceedings or

5. This affidavit is being executed to support my request for the release

of the impounded vehicle,

6. I am executing this undertaking to attest to the truth of the


IN WITNESS WHEREFOR, I have hereunto set my hands this day of

, 2012 in Naga City, Philippines.

SUBSCRIBED AND SWORN TO before me this day of ,2012

in the City of Naga, Affiant Exhibiting to me his issued on
December 15, 2011 in Manila, Philippines.

Doc No.
Page No. Notary Public
Book No.
Series of 2012