Republic of the Philippines )

City of Makati ) S.S.

x--------------------------x

AFFIDAVIT

I, _____________________________ of legal age, Filipino citizen, ___________ and presently residing at _________________ ___________________, after having been duly sworn to in accordance with law, do hereby depose and say:

1. That I am the widow of BENITO D. DELA CRUZ who died on July 30, 2013 in Quezon City because of head injuries sustained in a vehicular accident as per autopsy result conducted by Dr. Lito R. Santos;

2. That per investigation of the Quezon City Police Station, my husband was driving along the northbound lane of EDSA in front of Camp Aguinaldo in Quezon City when he was hit/bumped by a truck coming from the opposite direction; copy of the Traffic Investigation Report is hereto attached as Annex "A";

3. That at the time of the incident, my husband was a duly licensed driver carrying Driver's License No. 123456 and was riding on a Toyota Innova, gray in color and with Plate No. XYZ-123 owned by me with Certificate of Registration No. 55667788;

4. That I am executing this affidavit in support of my application for insurance claim with _____________, to attest to the truth of the foregoing, and for whatever legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 6th day of October 2013 at Makati City, Philippines.

_______________________________

Affiant

SUBSCRIBED AND SWORN to before me, this ____ day of __________ 20____, in the City of __________________, by ___________________ with Passport No.________________ issued on __________________ at _____________.

Notary Public

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of ______;