Republic of the Philippines )

Province of Bulacan ) s.s.

Municipality of Baliwag)

AFFIDAVIT OF ACCIDENT /DRIVER’S AFFIDAVIT

I, JHANRY E. PINEDA, of legal age, single, Filipino, and a resident of 117 Cut-cot, Pulilan
Bulacan, after having been sworn in accordance with law, do hereby depose and say:

1. That I am the registered owner of a TOYOTA WIGO G 2020 model with Engine No.
1KRA524457 and Chassis No. MHKA4DE5FKJ012358 and Plate No. ___________ ;

1. That I use the above-mentioned vehicle in reporting for work and for personal use ;

2. That I am also the holder of a valid Driver’s License issued by the Land Transportation
Office (LTO) ;

3. That sometime on February 3, 2020 at around 3 pm, I went to SM City Baliuag at Pinagpala,
Baliuag, Bulacan, for a personal transaction and used the above-mentioned vehicle ;

4. That as I was about to maneuver into the parking slot at SM in reverse, I miscalculated the
distance and the rear bumper of the vehicle came into contact with the parking steel railing ;

5. That upon immediate inspection, the rear bumper portion had suffered some dents and
scratches from the impact ;

6. That I was driving carefully and was not disobeying any motoring laws or regulations during
the incident and am in possession of a Driver’s License ;

7. That the incident was a simple case of negligence and human error on my part ;

8. That I am executing this affidavit for the purpose of attesting to the facts as stated above;

9. That I am also executing this affidavit for the purpose of claiming indemnity for the damages
suffered by the vehicle from the Insurance Policy for the said vehicle ;

IN WITNESS WHEREOF, I have hereunto set my hand this July 27, 2020, at the Municipality
of Baliwag, Province of Bulacan.

JHANRY E. PINEDA
Affiant

SUBSCRIBED AND SWORN to before me this July 27, 2020 at the Municipality of Baliwag, Province of
Bulacan, affiant showing to me his Driver’s License.

ATTY. CRISTOBAL R. FERNANDEZ IV

NOTARY PUBLIC
Until December 31, 2020
PTR No. 4426306 /January 8, 2020
IBP OR No. 111069/ January 8, 2020
MCLE NO. VI 0028766 / Sept. 19, 2019
Doc. No. __________ ; Roll No. 57387
Page No. __________ ;
Book No. __________ ;
Series of 2020 .
Republic of the Philippines )
Province of Bulacan ) s.s.
Municipality of Baliwag)

AFFIDAVIT OF ACCIDENT /DRIVER’S AFFIDAVIT

I, JHANRY E. PINEDA, of legal age, single, Filipino, and a resident of 117 Cut-cot, Pulilan
Bulacan, after having been sworn in accordance with law, do hereby depose and say:

2. That I am the registered owner of a TOYOTA WIGO G 2020 model with Engine No.
1KRA524457 and Chassis No. MHKA4DE5FKJ012358 and Plate No. ___________ ;

3. That I use the above-mentioned vehicle in reporting for work and for personal use ;

4. That I am also the holder of a valid Driver’s License issued by the Land Transportation
Office (LTO) ;

5. That sometime on March 24, 2020 at around 8 am, I reported for work at the Security Bank
Plaridel Branch ;

6. That as I was about to maneuver into the parking slot at Security Bank in reverse, I failed to
notice the presence of a parked single motorcycle in the parking slot and accidentally bumped
into it ;

7. That upon immediate inspection, the rear bumper portion had suffered some dents and
scratches from the impact ;

8. That I was driving carefully and was not disobeying any motoring laws or regulations during
the incident and am in possession of a Driver’s License ;

9. That the incident was a simple case of negligence and human error on my part ;

10. That I am executing this affidavit for the purpose of attesting to the facts as stated above;

11. That I am also executing this affidavit for the purpose of claiming indemnity for the damages
suffered by the vehicle from the Insurance Policy for the said vehicle ;

IN WITNESS WHEREOF, I have hereunto set my hand this July 27, 2020, at the Municipality
of Baliwag, Province of Bulacan.

JHANRY E. PINEDA
Affiant

SUBSCRIBED AND SWORN to before me this July 27, 2020 at the Municipality of Baliwag, Province of
Bulacan, affiant showing to me his Driver’s License.

ATTY. CRISTOBAL R. FERNANDEZ IV

NOTARY PUBLIC
Until December 31, 2020
PTR No. 4426306 /January 8, 2020
IBP OR No. 111069/ January 8, 2020
MCLE NO. VI 0028766 / Sept. 19, 2019
Doc. No. __________ ; Roll No. 57387
Page No. __________ ;
Book No. __________ ;
Series of 2020 .
Republic of the Philippines )
Province of Bulacan ) s.s.
Municipality of Baliwag)

AFFIDAVIT OF ACCIDENT /DRIVER’S AFFIDAVIT

I, JHANRY E. PINEDA, of legal age, single, Filipino, and a resident of 117 Cut-cot, Pulilan
Bulacan, after having been sworn in accordance with law, do hereby depose and say:

1. That I am the registered owner of a TOYOTA WIGO G 2020 model with Engine No.
1KRA524457 and Chassis No. MHKA4DE5FKJ012358 and Plate No. ___________ ;

1. That I use the above-mentioned vehicle in reporting for work and for personal use ;

2. That I am also the holder of a valid Driver’s License issued by the Land Transportation
Office (LTO) ;

3. That sometime on July 24, 2020 at around 5 pm, I went to Bagna, in Malolos City for an
errand ;

4. That as I was trying to park the vehicle, the passenger side (right side) portion of the vehicle
came into contact with a barbed steel wire which fenced the surrounding lot where I had
parked ;

5. That upon immediate inspection, the front passenger door suffered a deep scratch on its paint
as a result of the impact ;

6. That I was driving carefully and was not disobeying any motoring laws or regulations during
the incident and am in possession of a Driver’s License ;

7. That the incident was a simple case of negligence and human error on my part ;

8. That I am executing this affidavit for the purpose of attesting to the facts as stated above;

9. That I am also executing this affidavit for the purpose of claiming indemnity for the damages
suffered by the vehicle from the Insurance Policy for the said vehicle ;

IN WITNESS WHEREOF, I have hereunto set my hand this July 27, 2020, at the Municipality
of Baliwag, Province of Bulacan.

JHANRY E. PINEDA
Affiant

SUBSCRIBED AND SWORN to before me this July 27, 2020 at the Municipality of Baliwag, Province of
Bulacan, affiant showing to me his Driver’s License.

ATTY. CRISTOBAL R. FERNANDEZ IV

NOTARY PUBLIC
Until December 31, 2020
PTR No. 4426306 /January 8, 2020
IBP OR No. 111069/ January 8, 2020
MCLE NO. VI 0028766 / Sept. 19, 2019
Doc. No. __________ ; Roll No. 57387
Page No. __________ ;
Book No. __________ ;
Series of 2020 .