REPUBLIC OF THE PHILIPPINES]

PROVINCE OF ]
CITY OF ] S.S.
x - - - - - - - - - - - - - - - - - -- - - /

AFFIDAVIT OF UNDERTAKING
I, __________________, of legal age, Filipino, single and a resident of
_______________________, Philippines after having been duly sworn to in accordance
with law, do hereby depose and say;

That I am the same and identical person who caused for the execution this
instrument;

That I am the registered owner of a motor vehicle, which is more particularly

described as follows:

Make : Plate No. :

Chassis No. : Engine No. :
MV File No. : Body Type :

That sometime on ________________ at about ____________, the said motor

vehicle met a vehicular accident at __________________;

That at that time it was driven by ________________, the collector of

_______________;

That in view of the said vehicular accident, the above-described motorcycle was
taken in the custody of ____________________;

That I am requesting the said station to release the above-described motor

vehicle and if the same will be needed by the said office anytime, then I undertake to
surrender the said motor vehicle to them for any legal purpose;

That I executed this affidavit of undertaking in order to attest that we are the
lawful owner of the above-described vehicle and I undertake to surrender the same to
the proper authorities for whatever legal purpose if needed;

In witness whereof, I have hereunto set my hand this ____________ at

_______________________, Philippines.

____________________
Affiant
____________________

Subscribed and sworn to before me this _____________ at

_________________, Philippines, affiant exhibited to me his Valid ID NO. as above
stated.