REPUBLIC OF THE PHILIPPINES)

IN THE CITY/MUN.OF _____________________)

X ----------------------------------------------------------- X
AFFIDAVIT OF TWO (2) DISINTERESTED PERSONS
We, _________________________________ of legal age, Filipino,
__________________ and a resident of ____________________________________ and
___________________________________
also
of
legal
age,
Filipino,
__________________
and
a
resident
of
________________________________________ after having been duly sworn to law,
depose and state that:
1. That we personally know the vehicular accident that occurred on
________________________ along _________________________________________
particularly at _________________________________________ involving Motor
Vehicle __________________________________ bearing Registered Plate No.
_____________ driven by certain ______________________________________;
2. That certain _____________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________;
3. That we know these facts and circumstances because we were among the
_______________________________________________________________________
_______________________________________________________________________
__
_______________________________________________________________________
_
_______________________________________________________________________;
4. That we are executing this affidavit to attest the truth of the foregoing
statements;
IN WITNESS WHEREOF, WE HAVE hereunto set our hands this ________th
day of __________________________ at ____________________________________,
Philippines.
________________________________
_______________________________
(Affiant)

(Affiant)

SUBSCRIBED AND SWORN to before me this ____________ day of

______________________________ at _____________________________________,
Philippines.

Doc. No. __________

Page No. __________
Book No. __________

Series of __________