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Republic of the Philippines) S.S.

City of Tarlac )


I, RECTO A. DOMINGO, Filipino, of legal age, married, and a resident of

Lalapac, Victoria, Tarlac, Philippines, after being duly sworn to in accordance with
law, hereby depose and state:

1. That I am a duly licensed driver with Professional Driver's License No.

_______________________ which is valid until _____________.

2. That on 28 May 2018, at around 7:30 pm, I was driving a vehicle,

owned and registered in the name of MARK KRISTOFERSON R. APOLONIO
which is more particularly described as follows:

Make: FORD Engine No.: P4AT2302421

Series: RANGER DBL 2.2L Chassis No.: MNCUMFF80GW625233
Body Type: PICK-UP Plate No.: ZTL177
MV File No.: 0301-00000-256549

3. That while I was driving along Roxas Blvd., Cubao towards EDSA,
suddenly the right-rear tire blew out. As a result,;

5. That there were no traffic enforcers at the time of the accident;

6. That I am executing this Affidavit to attest to the truth of the foregoing

and in support of the claim against the insurer for the repair of the damage
caused to the said company vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this

______________ in the City of Tarlac, Philippines.


SUBSCRIBED AND SWORN to before me, this ___________ in the City

of Tarlac, Philippines.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2018.