Republic of the Philippines )

City of Kabankalan ) s.s.

x…………………………………….x

AFFIDAVIT

I, JOAN GAYUMALI y MANONGSONG, of legal age, Filipino, married

and a resident of FZO Subd., Barangay 1, Kabankalan City, Negros
Occidental, after having been duly sworn to in accordance with law,
hereby depose and state:

1. That I am an ambulance driver of the City Government of

Kabankalan particularly described as: white, Toyota Hi-Ace Van
(UV) Ambulance of the City of Kabankalan, 2017 model with
Conduction Sticker no. VJ8268, Engine No. IKD2656909, Chassis No.
JTFJT02PI65UD5413, CR No. 261667582 and OR No. 10303731240
registered under the City Government of Kabankalan, HAR, City of
Kabankalan, Negros Occidental.

2. Sometime on April 14, 2019, at around 11:15 AM, at the Municipality

of Pulupandan, while on my way to transport a patient to Bacolod
City, I was tailing a black, Suzuki pick-up with canopy, 2011 model
bearing plate no. 1619 FK, Engine No. FGA54 86162, Chassis No.
DC5IT 340677, CR No. 12817903-2 and OR No. 802 698120 owned by
Antonio Pesiao y Allego of legal age, married and resident of Brgy.
Mabini, Pulupandan, Negros Occidental.

3. With my audible sirens blaring, I turned my signal light as I was

about to overtake the pick-up when the latter prematurely made a
left turn without clearing his way for a possible oncoming vehicle.

4. This lack of precaution from Mr. Pesiao has resulted into a collision
of the two vehicles. The ambulance sustained damages on the right-
side portion and also at the right side front portion of the door of the
vehicle. Other damages are also visibly seen on the vehicle. Attached
herewith are photos of the damages sustained by the ambulance as
Annex “A”, “A-1”, “A-2”. “A-3” and “A-4”.

5. The above-described damage sustained by the ambulance is

estimated to amount to One Hundred Thirty-Eight Thousand Pesos
(PhP138,000.00). A copy of the estimate for repair issued by Toyota
Service Center is hereto attached as Annex “B”.

6. That the said incident was reported to the Pulupandan Municipal

Police Station and recorded in the Police Blotter Book as Entry No.
 2019-0670 dated April 15, 2019. Attached herewith is a copy of the
Blotter Report as Annex “C”.

7. I execute this Affidavit to attest to the truth of the foregoing facts and
declarations, and for the purpose of the claiming the insurance
proceeds of the said vehicle registered under the City Government of
Kabankalan.

8. That, I further execute this Affidavit for whatever legal purpose it

may serve.

IN WITNESS WHEREOF, I hereby affix my signature this ___ day of

May 2019, at Kabankalan City, Philippines.

JOAN GAYUMALI y MANONGSONG

Affiant

SUBSCRIBED AND SWORN TO before me this __ day of May

2019, at Kabankalan City, Negros Occidental, Philippines. Affiant
personally appeared before me and exhibited his
______ Identification Card with Serial No. ____________ as his
competent evidence of identity.

Doc No. ______;

Page No.______;
Book No.______;
Series of ______.