You are on page 1of 1

Republic of the Philippines)

Province of Southern Leyte) s.s.

Municipality of Tomas Oppus.)


I, CECILIA T. CABAGUING, of legal age, Filipino, married and with postal

address at Purok Sambag, Brgy. Mantahan, Maasin City, Southern Leyte,
after having been duly sworn to in accordance with law, do hereby
depose and state THAT:

1. I am a duly licensed driver with Driver's License No. H10-99-

000636, which is valid until July 7, 2019;

2. On November 28, 2018, at around 6:00 o’clock in the morning, I

was driving a motor vehicle owned and registered in the name of
Violeta B. Felisilda which is more particularly described as follows:

Make: Honda
Plate No.: DV6837
Engine No.:L15213964318
Chassis No.:MRHDG1840HP001807

3. While I was driving along Brgy. Timba, Malitbog, Southern Leyte,

the aforementioned vehicle suddenly hit a dog and as a result the
said vehicle sustained damage at its bumper front, condenser,
and lower bulkhead estimated at Fifty Nine Thousand Eight
Hundred Sixty Eight Pesos Only(Php59,868.00) Copy of the Final
Estimate is hereinafter referred to as Annex “A”;

4. I am executing this Affidavit to attest to the truth of the forgoing

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

IN WITNESS WHEREOF, I have hereunto set/affixed my signature this 14th

day of January 2019 at Tomas Oppus, Southern Leyte, Philippines.

Driver’s License No. H10-99-000636

SUBSCRIBED AND SWORN TO before me this 14thday of January at

Tomas Oppus, Southern Leyte, Philippines.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2019