Republic of the Philippines)

Province of Cavite ) SC

AFFIDAVIT

I, LEON MAGNO BAUTISTA GELLE, of legal age, married, Filipino citizen, and with
residence address at Aguinaldo Highway, City of Dasmariñas, Cavite, Philippines, after
having been duly sworn to according to law, hereby depose and state that:

1. That I am a holder of Non-Professional Driver’s License Card issued by Land

Transportation Office (LTO) with corresponding license number D02-82-013057 valid
until 2022-04-11;

2. That I am the registered owner of a vehicle which is more particularly described as

follows:

Make : Mitsubishi Engine No. : 4D56AN2865

Series : L200 Strada Chassis No. : PAEK74NX13B000340
B. Type: Pick-up MV File No. : 1391-00000003803
Yr. Model: 2003 Plate No. : XMS101

3. That on August 17, 2019, while my vehicle was being parked in our house, it was
accidentally hit by a truck owned by Red Ribbon company;

4. As a result of the said incident, my vehicle sustained damages ;

5. That as of the present time, the vehicle above described, which I own is not under
any comprehensive vehicle insurance by any insurance company;

6. I am executing this AFFIDAVIT to prove the veracity and truthfulness of the

foregoing facts and to attest to the truth of the foregoing circumstances and for the
purpose of reporting the matter to the insurance office for the insurance claims.

IN WITNESS WHEREOF, I have hereunto set my hands this 27 th day of August, 2019 in the
Province of Cavite, Philippines.

LEON MAGNO BAUTISTA GELLE

Affiant

SUBSCRIBED AND SWORN TO before me this 27 th day of August, 2019 in the Province of
Cavite, affiant exhibiting to me his Competent Evidence of Identity consisting of driver’s
license bearing number D02-82-013057 valid until 2022-04-11.

Doc No._______
Page No._______
Book No._______
Series of 2019.