REPUBLIC OF THE PHILIPPINES QUEZON CITY

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S.S.

AFFIDAVIT OF VEHICULAR ACCIDENT I, _______________________, (civil status), of legal age, a resident of ______________________________________ after being sworn in accordance with law, hereby depose and say: That I am the holder of a Professional Drivers License No. ____________ issued by the LTO of __________________________ and valid until ______________________; That I am an employee of Valiant Distribution, Inc/Mckenzie Distribution Co. Inc. and as such I am assigned a car more particularly described as follows: Make: Year Model Plate No. CR No. OR No. That on ____________________, at around ____________(time), more or less, I was driving the aforementioned vehicle on my way to __________________ from ____________________; That (make a brief statement of the accident) That the aforementioned situation was an accident beyond my control after exercising extraordinary care and diligence to safety; That the same extraordinary care and diligence was exercised when I took control of the situation by immediately applying the brakes and preventing a more fatal vehicular accident. That I execute this AFFIDAVIT to attest to the veracity of the facts stated herein and for insurance claims purposes. Done this _____________ 2012 at Quezon City.

_______________________________________ Affiant CTC. No. _______________________ Issued on _______________________________ Issued at _______________________________

Subscribed and sworn to before me this ___________ day of _____________2012 at Quezon City, Philippines. Doc. No. _______ Page No. _______ Book No. ______ Series of 2012.