Republic of the Philippines )

)S.S.

AFFIDAVIT

I, LYLE I. CAMUS, of legal age, single, Filipino citizen and a resident of 478 Maharlika
Highway, Maligaya, Science City, Muñoz, Nueva Ecija, after having been duly sworn to in
accordance with law do hereby depose and say:

1. That I am the driver of a Mitsubishi Mirage G4, more particularly described as

follows:

Make Model : MITSUBISHI

Plate No. : NDM 2023
Engine No. : 3A92UJA5499
Chasis No. : PAEA13TXKKA008725
Series : MIRAGE G4 GLS 1
Body Type : SEDAN
Year Model : 2019
Color : WINE RED PEARL

2. As a driver, I am a holder of a valid driver’s license with no. C11-12-011679;

3. That on October 25, 2020 at around 8:00 in the morning, while I am in the NLEX
Southbound, the truck with Plate No. NZG 312, was in front of me;

4. Suddenly, the steel which is part of the truck fell and hit the front portion, as well as
the under chasis of my car, causing damage to it;

5. Attached are the Official Receipt and the Certificate of Registration of the Mitsubishi
Mirage for purpose of applying for insurance coverage for the repairs of the same;

6. That this affidavit is being executed to attest to the truth of the foregoing, and for
other legal purposes this may serve.

______________________, Quezon City.

LYLE I. CAMUS
Affiant
Driver’s License No. C11-12-011679

Subscribed and sworn to before me, affiant personally appeared on the place and date
above-written, exhibiting her valid identification card with picture.

Doc No ______ NOTARY PUBLIC

Page No _____
Book No _____
Series of 2020