I, _________, of legal age, married and with residence address at _________after having been duly sworn to according to law, hereby depose and state:

           1. That I am the registered owner of a motor vehicle which is specifically described as follows:

           2.That said motor vehicle figured in an accident on October __, At about 6:40pm while I was driving it along Stella Maris St. and as I was trying to turn left at the corner of Dr. Sixto Antonio Avenue in Pasig City, an Isuzu Elf with Plate No. ___ driven by a certain _______ tried to overtake me in the inner portion of that corner thus grazing and scraping the left hand fender liner, left hand side view mirror, dents in the front and rear doors on the left hand side which thus sustained considerable damage to my said vehicle.

           3.As we were both in a hurry and I was still in my bedroom shorts as I was just about to bring my daughter to school, we did not bother anymore to summon a policeman to record the accident;

           4.That I am executing this affidavit in order to attest to the truth of the foregoing circumstances and for the purpose of reporting the matter to my insurance office for insurance claims.

           IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of October, 2003 at the City of Makati.