REPUBLIC OF THE PHILIPPINES)
) S.S.
I, (Name), of legal age, Filipino, married and a resident of (Address), after having been duly sworn to in accordance with law, depose and state:
That I am the widow of (Name of Husband) who died on (Date of Death) in Meycauayan City because of severe injuries sustained in a vehicular accident as per autopsy result conducted by Dr. ---------;
2. That per investigation of the Meycauayan City Police Station, my husband was driving along the southlane of Meycauayan Interchange in front of Sterling Industrial Park in Meycauayan 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. 00000 and was riding on a Toyota Innova, gray in color and with Plate No. AAA-000 owned by me with Certificate of Registration No. 000000000;
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 (Date) in (Place), Philippines.
(Name)Affiant
SUBCRIBED AND SWORN TO before me this (Date) in (Place), Philippines by (Name of Affiant) affiant exhibiting to me his Competent Evidence of Identity by way of Passport Identification (ID Number) issued on (Date) in (Place).
Notary Public
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 20__.