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Republic of the Philippines ))

City of Calbayog )) s.s.

I, ANTONIO JR TAN GO, Filipino, 62 years of age, married, and presently a
resident of Juan Luna Street, Tondo, Manila, Philippines, after having been duly sworn
to in accordance with law, hereby depose and state, that--

1. I am the driver with License Number N04-79-020558 of Toyota Super Grandia

Hi-ace particularly described as:

Engine Number: 2KDA357389

Chasis Number: JTFRS13P90031285
Plate Number: AA04975
Color: White

2. The said vehicle is registered under the name of SAMMY L. SY;

3. On 27 May 2018 at around 2:45 in the afternoon, while traversing the roads of
Maharlika Highway in San Jorge, Samar, bound to South, said vehicle was
accidentally bumped by a 2018 Ford Ranger vehicle driven and is registered
under the name of Jimmy Russel David Manansala;

4. The said incident caused damage and dents to the vehicle;

5. The same vehicle, together with two (2) other vehicles are still at the said hi-
way properly cordoned by the PNP officers and is under their custody and
control pending investigation of the incident;

6. I am executing this Affidavit to attest to the truth of the foregoing facts and to
request for release of the vehicle by the PNP officers in custody of the same and
for whatever legal purpose this may serve;

7. That upon release of the same, I undertake to take custody and deliver it to the
proper authorities whenever required.

IN WITNESS WHEREOF, I have hereunto set my hand this 28th day of May
2018, at Calbayog City, Philippines.

Driver’s License: N04-79-020558

SUBSCRIBED AND SWORN TO BEFORE ME, this 28th day of May 2018, at
Calbayog City, Philippines.


Public Attorney I
Pursuant to RA 9406

Doc. No. 179;

Page No. 9;
Book No. I
Series of 2018