Republic of the Philippines) Province of_________________)S.S.

City/Municipality of___________ x----------x AFFIDAVIT I, _____________,Filipino, of legal age,(single / married / widow),and a resident of _____________, Philippines, after being sworn in accordance with law, depose and state: That I am a duly licensed driver with Driver's License No.___________, which is valid until the year________and that I usually drive a vehicle in bringing my son to school at ____________, which vehicle is specifically described as a __________with Motor No.____________, Chassis No. ___________and with late No.___________issued by the Land Transportation Office of the City of Bacolod and is registered in the name of____________,with Certificate of Registration No.____________issued on____________and with MVMRR No. _____________dated___________; That on__________at around _______PM, when I brought my son to school and when the said vehicle was parked at____________, another vehicle, identified as a____________with Plate No. _____________and_____________ in color, stopped in front of my vehicle to also bring an a student to school; That after the student who alighted from the said _____________had entered the school gate, the driver of the said____________, recklessly and impudently, tried to make a U-Turn and hit / bumped my vehicle and that when I instantaneously blew my horn, the driver of the said ___________quickly accelerated and feloniously fled away in the direction going to____________; That as a result of the incident, the _____________I was driving sustained damage in its ____________. That the said incident was witnessed by many persons, most of whom are also parents of students who were likewise bringing their children to school, and has been duly documented in the Blotter of the Traffic Division of the ____________. That upon inquiry with the Security Office of the___________, it was discovered that the said ____________has been issued a Car Pass by the school upon application of a certain___________, a Grade________student of_____________, with residence at ____________. That I am executing this Affidavit to attest to the truth of the foregoing and in support of charges for"RECKLESS IMPRUDENCE" against the driver of the said____________or for whatever other action that may be filed against the driver and/or registered owner of the said vehicle and in support of claims against the insurer for the repair of the damage caused to the vehicle I was driving. IN WITNESS WHEREOF, I have hereunto set my hand this____________in_____________, Philippines. AFFIANT (JURAT)