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AFFIDAVIT

I .. S/o Sh. ., R/o ..


.., Punjab, do hereby solemnly affirms and declared as under:1.

That I . am the owner of the Maruti Ertiga No.


.. Bearing chassis no Engine no.
.., Regd.at ., date of Registration ..

2. That my said car met with an accident on . at about 11:00 AM near


.
3. That at the time of accident Sh. Jasvir Kumar driving the vehicle.
4. I hereby also confirm that no third party loss was arise and no one received any
injuries in the mishap and if any third party loss arise in the said mishap I shall be
fully responsible for that.

Deponent
Verified that statement furnished above is true and correct to be best of my knowledge
and belief and nothing has been concealed.

Deponent

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