Republic of the Philippines )

City of Dipolog ) S.S

x--------------------------------x

AFFIDAVIT OF CAR ACCIDENT

I, ZOILO DELOS SANTOS III, of legal age, Filipino and with office address at
DTL warehouse Door 8/9, Minaog, Dipolog City, having duly sworn in accordance with
law, do hereby depose and state that:

1. That I am the driver of the following described-vehicle, to wit:

Make :HYUNDAI
Model :2010
Plate # :PNQ 481
Engine :D4FAAU881103
CHASIS : KMHCM41VABU553917

2. That on July 06, 2019 at around 5:30 in the morning in Sianib, Polanco,
Zamboanga del Norte, while I was travelling towards north direction and
upon reaching the aforesaid place, I accidentally swerved and lost control of
the steering wheel due to heavy rain and the road was muddy and loose
gravel abound that resulted overshot to the cliff and incurred damages due to
the incident;

3. I am executing this affidavit to attest to the truth of the foregoing and for
whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto affixed our hands this _______________

at Dipolog City, Philippines.

ZOILO DELOS SANTOS III

Affiant

SUBSCRIBE AND SWORN TO before me this ____________ at Dipolog City,

Philippines, with affiant exhibiting to me his Valid ID NO.Driver’s License No.
K0411001095.

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Republic of the Philippines )
City of Dipolog ) S.S
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AFFIDAVIT OF LOSS

I, FREDERICK S. CALOG, of legal age, Filipino, married and a resident of

Barangay Alvinda, Mutia, Zamboanga del Norte, after having duly sworn in accordance
with law, do hereby depose and state that:

1. That I am a holder of an Official Receipt from a purchase of a chainsaw in

Oroquieta City in the year 2017 which is more particularly described as
follows:
BRAND SERIAL MACHINE NO.

ZERO70 STEEL S178200084

2. That the said document while in my possession was misplaced and could no
longer ne located inspite of exerting efforts of locating them;

3. That I am executing this affidavit to attest the truth of the foregoing and for
whatever legal purpose it may serve.

AFFIANT FURTHER SAYETH NAUGHT.

IN WITNESS WHEREOF, we have hereunto affixed our hands this____ day of

_______________ at ________________.

FREDERICK S. CALOG
Affiant
Philhealth ID 16-050166521-2

SUBSCRIBE AND SWORN TO before me this August 31, 2018 at Dipolog City.

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Series of 2018.