AFFIDAVIT OF ACCIDENT

I, CRISOSTOMO SAPALARAN ALDAY, of legal age, Filipino, married, and a resident of 118 Santor,
Malolos, Bulacan, after having been duly sworn to in accordance with law, do hereby deposes and
states:

1. That at 5:37 in the morning of June 9, 2021, I was driving an Isuzu closed van with
license plate AIA 2084 along the stretch of NLEX after the Marilao Toll Exit,
Southbound;

2. That approximately on the said time and date, a pickup truck overtook the said
vehicle on my left side;

3. That as the pickup truck passed by the said Isuzu van, a rock flew and hit the driver
side windshield of the vehicle I was driving that caused irrepairable damage to the
windshield.

4. That I voluntarily execute this Affidavit for the purpose of insurance claim and
further, to attest the truth of all foregoing and for other legal intents and purposes it
may serve.

IN WITNESS WHEREOF, I have hereto affixed my signature this 9th of June, here at Malolos, Bulacan.

CRISOSTOMO SAPALARAN ALDAY

Affiant

SUBSCRIBED AND SWORN to before me this 9 th of June 2021, at Malolos City, Bulacan, affiant exhibiting
to me his Driver’s License Number C07-98-160809, and known to me and to me known personally to be
the same person who executed the foregoing Affidavit

Doc. No. ___; NOTARY PUBLIC

Page No. ___;

Book No. ___;

Series of 2021.