Republic of the Philippines )

Quezon City ) SS.

AFFIDAVIT

I, JOSE GABRIEL LAZARO JAPLOS, Filipino, of legal age and a resident of 35

Finland St., Loyola Grand Villas, Pansol, Quezon City, after having been duly sworn in
accordance with law, hereby depose and say:
1. That I am a holder of a Non-Professional LTO Driver’s License with No. D19-
16-011755 issued on 14 May 2019 and valid until 14 May 2024;

2. That on 29 August 2020, I was driving along Julia Vargas Avenue, Pasig City,
using a motor vehicle owned and registered in my father’s name which is
more particularly described as follows:

Make : Mazda
Model : CX90
Plate No. : WOM 563

3. That day, traffic was light and I was leisurely driving, slightly moving from left
lane to the middle lane since I was going straight. While in the middle lane, I
drove slightly faster since there were no vehicles in front of me when
suddenly a black vehicle appeared to my right and sped past me a few
meters ahead;

4. While also in the middle lane, the black vehicle suddenly turned left without
making any signal that it will turn left;

5. The abrupt turn which I did not expect, hit the headlight of my motor vehicle
and caused some scratches on the hood and dent on the right passenger
door;

6. The black vehicle did not stop and continued its way while I stopped
somewhere ahead to check the damage caused to the vehicle I was driving;

7. I was not able to take the plate number of the black vehicle, but I did note
that it was a sedan;

8. That I am executing this Affidavit to attest to the truth of the foregoing and
in support of my claim against the insurer for the repair of the damage
caused to our vehicle.

IN WITNESS WHEREOF, I hereunto affix my signature this 7th day of

September 2020 at Quezon City, Philippines.

JOSE GABRIEL LAZARO JAPLOS

Affiant
 SUBSCRIBED AND SWORN to before me this 7th day of September 2020 in Quezon
City, where Affiant personally appeared and exhibited to me his Driver’s License with number
D19-16-011755 issued on 14 May 2019 and valid until 14 May 2024 as competent proof of his
identity.

Doc. No. 116 ;

Page No. 25;
Book No. 01;
Series of 2020.