Republic of the Philippines )

Province of Palawan ) S.S.

AFFIDAVIT

I, ARIEL A. ABIS, Filipino, of legal, single and with residence at Block 7 Lot
2, DJD Village, Napocor Road, San Manuel, Puerto Princesa, after being duly
sworn in accordance with law, depose and state:

1. That I am an owner of a Cool Silver 2017 MIRAGE GLX 1.2 G with Engine
No. 3A92UGJ1221, Serial No. PAEA03NJHHA000118 and C/S No. B1-
J718;

2. That I have a driver’s a license issued by the Land Transportation

Authority (LTO) with Driver’s License No. D11-18005283;

3. That around 5:30 pm in the afternoon of January 6, 2019 while I am

driving my Silver Mitsubishi Mirage GLX with conduction sticker no.
B1J718 from Manalo Extension going to Jacana Road, Bancao-Bancao,
Puerto Princesa City I was accidentally bumped in the rear portion by a
Toyota Avanza with plate No. AAR6109 owned by MILDRED MADUMMA
and driven by CINDY PACIA MADUMMA without driver’s license and
accompanied by RONALD BERNAS QUIRAY causing damages in the rear
portion of my car;

4. Aside from the damage to the rear portion of my car, the driver seat of my
car had slightly bended to the right cause by the strong impact of the
bumped in the rear portion;

5. Afterwards I immediately brought it to the service center;

6. As such, I am executing this Affidavit to attest to the truth of the foregoing

and for whatever legal purposes that this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 10th of January

2019 at Puerto Princesa City, Philippines.

ARIEL A. ABIS
Affiant

SUBCRIBED AND SWORN TO before me this 10th January 2019 in Puerto

Princesa City, Palawan, Philippines, affiant exhibiting to me his competent
evidence of identity by way of his Driver’s License with No. D1117S15574.

Notary Public

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2019