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

AFFIDAVIT OF PROTEST

I, ________, Filipino, of legal age, with address at ________, after being duly sworn according to law, hereby depose and state that:

1. I am the driver of the motor vehicle as mentioned below:

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

2. My driver's license number is: ________.

3. While I was driving along: ________, I was flagged down and apprehended by a traffic enforcer named: ________.

4. I was issued a citation ticket with the number: ________, dated ________, and was imposed a fine with a total amount of ₱________ (________). Attached herewith is a copy of the same.

5. Under the citation ticket, it states that I committed the following traffic violations:

________

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________

7. The proof attesting the truthfulness of the foregoing is likewise herewith attached:

________

8. I am executing this affidavit to protest and contest the violations cited in the citation ticket.

9. I am executing this affidavit to attest to the truthfulness of the foregoing statements and for whatever legal purpose this may serve.

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________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this _________ day of ______________________, 20______ at CITY OR MUNICIPALITY OF ________________________, ________________________

Affiant, ________ personally appeared before me and exhibited to me Postal ID no. ________ which is valid until ________.

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