AFFIDAVIT OF DESISTANCE

I, _____________________, Filipino, of legal age, and resident of

_______________________________________________ after having been duly sworn to in
accordance with law, depose and state:

1. That I am the owner of a private vehicle _________________ having a plate number

_________________ driven by _____________________ having a professional driver’s
license number __________________ which will expire on __________________.

2. That on January 14, 2019, my vehicle had incidentally hit/bumped by a ______________

having a plate number of __________ owned by ________________ driven by
__________________________with professional driver’s license _____________, which
will expire on ___________;

3. That my vehicle had incurred damaged on left side rear portion and none was injured;

4. That I fully understand and accept that said unfortunate event is purely accidental in nature
and was not attended by negligence on the part of the driver or owner;

5. That the owner of the vehicle with plate number _____________, __________________,
had likewise extended to my full satisfaction all the assistance that he could provide to
cover the expenses incurred owing to the repair and labor of my car;

6. In view of foregoing, I do hereby freely, voluntarily, and absolutely release, clear, absolve,
and discharge the said _________________ and his driver _____________________ from
any action, cause of action, sum of money, liability, damages, claims and demands
whatsoever, which in law or in equity I have, or which I, my heirs, insurer, successors and
assigns, as a confession and/or admission of liability on his part or of his driver in
connection with the aforementioned accident;

7. That I have fully read or caused to be interpreted, and understood the contents of this
affidavit, that the same reflects my true intention, and I am also fully aware of the legal
effects of executing and signing of the same.

IN WITNESS WHEREOF, I have hereunto set my hands this ___________________ in

_______________, Philippines.

______________________
Affiant

SUBSCRIBED AND SWORN to before me, this ___________________, in

________________________________, by the above-named affidavit who presented to me his
________________________________ as competent evidence of his identity.

Doc No. _________;

Page No. _________;
Book No. _________;
Series of 2019.