REPUBLIC OF THE PHILIPPINES )
PROVINCE OF ________ )
CITY OR MUNICIPALITY OF ________ ) S.S.

AFFIDAVIT OF PROTEST

I, ________, Filipino, of legal age, single/married, with residence and postal address at ________, after having been duly sworn to in accordance with law, do hereby depose and state THAT:

§ 1. Personal Circumstances and Vehicle. I am the registered owner and/or authorized driver of the motor vehicle particularly described as follows:

Manufacturer or Brand: ________
Registration No.: ________
Plate No.: ________
Motor No.: ________
Chassis No.: ________

§ 2. Driver's License. I am a duly licensed driver, holding Driver's License No. ________, issued by the Land Transportation Office, valid until ________.

§ 3. The Apprehension. On ________, at approximately ________, while I was driving the above-described motor vehicle along ________, I was flagged down and apprehended by a traffic enforcer identified as ________, with badge/identification number ________, of the agency known as ________.

§ 4. The Citation Ticket. In connection with the foregoing apprehension, I was issued a citation/ordinance violation receipt bearing No. ________, dated ________, with an imposed fine and/or penalty in the total amount of ₱________ (________). A faithful copy of the said citation ticket is hereto attached as Annex "A" and made an integral part hereof.

§ 5. Alleged Violations. Under the said citation ticket, I am charged with having committed the following alleged traffic violation/s:

________

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________

§ 7. Supporting Evidence. In support of, and to attest to, the truthfulness of the foregoing statements, I hereto attach the following documents and evidence, collectively marked as Annex "B" and series:

________

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§ 9. Purpose. I am executing this Affidavit of Protest to attest to the truth of the foregoing statements, to formally contest the violation/s cited in the above-mentioned citation ticket, and for whatever lawful and legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ________ day of ________, 20________, at ________, Philippines.

________
Affiant

ACKNOWLEDGMENT / JURAT

SUBSCRIBED AND SWORN TO before me this ________ day of ________, 20________, at ________, Philippines.

The affiant, ________, personally appeared before me and is personally known to me or was identified by me through competent evidence of identity, namely Postal ID No. ________, issued at ________, valid until ________, and who is the same person who executed the foregoing Affidavit of Protest, and who acknowledged to me that the same is his/her free and voluntary act and deed and that of the entity he/she represents, if any.

I further certify that I have caused the affiant to sign the foregoing instrument in my presence, and that this instrument consists of ________ page/s, including this page on which this jurat is written, duly signed by the affiant and his/her instrumental witness/es, if any, and sealed with my notarial seal.

________
NOTARY PUBLIC

Doc. No.: ________;
Page No.: ________;
Book No.: ________;
Series of ________.