REPUBLIC OF THE PHILIPPINES)

SAN CARLOS CITY, PANGASINAN)S.S

AFFIDAVIT OF DRIVER

I, KARL EVERT B. TALABAN, of legal age, Filipino citizen, , and a resident of

Arellano St., Poblacion Malasiqui, Pangasinan, after having been duly sworn to hereby
depose and states that:

1. Sometime on January 11, 2021 at round 8 o’clock in the evening, I went to the
house of my sister’s boyfriend as they have invited me for dinner in San Carlos
City, Pangasinan;

2. Going to the dinner, I was driving the car the Mitsubishi Xpander with plate no.
IAC 9017and registered under the name of Leilani A. Baustista;

3. At round 12 to 12:30 midnight, I was already on my way home and was

traversing the road of Perez Blvd., San Carlos City, Pangasinan going to
Malasiqui, Pangasinan I looked at the rear view mirror of the vehicle I was
driving and when I looked at the road, there was suddenly a speeding
motorcycle appeared before me and was without any headlight;

4. I immediately did my best to prevent hitting the motorcycle and with the sudden
maneuver, I accidentally lost control and was shocked to have already hit the
side post of commercial building;

5. I was immediately rushed to the ER section of Villaflor hospital to seek

immediate medical attention as I have sustained minor bruises;

6. Due to the said accident, the motor vehicle incurred major damages with an
undetermined cost of repair;

7. That I am executing this Affidavit to attest to the truth of the foregoing and for
the purpose of claiming the insurance coverage for the said vehicle and for
whatever legal purposes it may best serve.

IN WITNESS WHEREOF, I hereto set my hand this ____ day of January 2021 in
San Carlos City, Pangasinan.

KARL EVERT B. TALABAN

Affiant
Driver’s License _________________
Valid until ______________________

SUBSCRIBED AND SWORN to before me ____ day of January 2021 in San

Carlos City, Pangasinan.

Notary Public