That I am the registered owner of L200 Pick up with Plate No.

RJS 488;

That on August 16, 2011 at about 9:30 o’clock in the morning, while I was traversing the North
Luzon Expressway near Marilao interchange going to South, stones suddently hit the windshield
and front passenger door of my pick up thereby resulting crack on the windshield and dent on the
front right side of the passenger door;
- ---

That I am a duly license driver with Driver’s License No. _____ which is valid until 5-11-19;
That on ___, at around ____ I was driving a vehicle owned and registered in the name of Faye V.
Sapitan which is more particularly described as follows:

That I wan slowly driving out our garage, I accidentally slammed the accelerator pedal instead of
the break, the aforementioned vehicle suddenly hit the wall of my neighborhood’s gate and as a
result the said vehicle sustained damage at its tailgate, bumper and backdoor.

That I am executing this affidavit to attest to the truth of the foregoing and in support of the
claim with the insurer for the repair of the damage caused to our vehicle.
- --

That I met an accident on June 1, 2020 at around 7pm while I was driving the said vehicle;

That on the said date and time, I was travelling along brgy. Meyto, Calumpit, Bulacan when
suddenly a motorcycle on the other side overtakes and to avoid hitting him I swerved
immediately to the right and sideswiped a tree that cause damage and scratches on right part of
the said vehicle.
---

REPUBLIC OF THE PHILIPPINES )

MALOLOS CITY, BULACAN. . . . .) S.S.

AFFIDAVIT OF ACCIDENT

I, VICENTE S. JOSON, of legal age, married, Filipino and resident of

225 Mabolo, Malolos City, Bulacan, after having been duly sworn to in
accordance with law, do hereby depose and say:

1. That I am the authorized driver of a motor vehicle, Toyota Innova with

Conduction Sticker No. A1-E698 registered under the name of Jollibee Foods
Corporation;

2. That on April 2, 2018 at around 7:00 A.M., while I was driving, I was
following a dump truck within Km. 32 South Bound of the North Luzon
Expressway and with the territorial jurisdiction of Balintawak, a stone
suddenly and accidentally hit my windshield;

3. That as a result of which, my windshield was damaged;

4. That I am executing this affidavit to attest to the veracity of the facts

contained herein and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 23 rd day of

April, 2018 at Malolos City, Bulacan.

VICENTE S. JOSON
Affiant
 SUBSCRIBED AND SWORN to before me this 23rd day of April, 2018 at
Malolos City, Bulacan, affiant exhibited to me his Driver’s License No. C07-87-
030155, a competent proof of identity, and known to me and to me known
personally to be the same person who executed the foregoing Affidavit.

REPUBLIC OF THE PHILIPPINES )

MALOLOS CITY, BULACAN. . . . . .) S.S.

AFFIDAVIT OF INSURANCE CLAIM

I, JEXZEL F. JINGCO, of legal age, single, Filipino and resident of

Sumapang Matanda, Malolos City, Bulacan, after having been duly sworn to in
accordance with law, do hereby depose and say:

1. That I am the authorized driver of a motor vehicle, Honda Mobilio

with Conduction Sticker No. DT2841 registered under the name of my
mother Emerita F. Jingco;

2. That last July 29, 2019 at around 3:00 in the afternoon, while
maneuvering said vehicle infront of MetroBank, MacArthur Highway, Malolos,
Bulacan, I accidentally bumped another vehicle (Toyota Vios) with Plate No.
CAC8141 registered under the name of Mary Sarah Gonzales Artoza;

3. That as a result of which the vehicle (Toyota Vios) sustained damage

at its left door, front side, while our vehicle sustained damage at its tail light
(left side) lower part;

4. The damage of Toyota Vios is estimated to be in the amount of

P28,990.42 evidenced by an estimate from Toyota Motors Plaridel, Bulacan
Branch.

5. That I am executing this affidavit to attest to the veracity of the facts

contained herein and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 31 st day of

July, 2019 at Malolos City, Bulacan.

JEXZEL F. JINGCO
Affiant

SUBSCRIBED AND SWORN to before me this 31 st day of July, 2019, at

Malolos City, Bulacan, affiant exhibiting to me his Driver’s License No.
_______________, a competent proof of identity, and known to me and to me
known personally to be the same person who executed the foregoing Affidavit

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2019.
REPUBLIC OF THE PHILIPPINES )
MALOLOS CITY, BULACAN. . . . . .) S.S.

AFFIDAVIT OF INSURANCE CLAIM

I, ANTHONY BEGOTA, of legal age, married, Filipino and resident of

B24 L35 Bulacan Meadows, Caypombo, Santa Maria, Bulacan, after having
been duly sworn to in accordance with law, do hereby depose and say:

1. That I am the owner of a motor vehicle, more particularly described

as follows:

MAKE/ MODEL COLOR CHASSIS ENGINE PLATE NO.

TYPE
Ford 2016 Mars Red MPBSXXMXK UEJAGK471 NCF 1257
Ecosport SGK47140 40

2. That last July 18, 2019 at around 4:00 in the afternoon, while
maneuvering said vehicle, I accidentally bumped a motorcycle which was
parked at the road side in Caypombo, Santa Maria, Bulacan;

3. That as a result of which my vehicle sustained damage at its left

door, front side;

4. That I am executing this affidavit to attest to the veracity of the facts

contained herein and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 20 th day of

August, 2019 at Malolos City, Bulacan.

ANTHONY BEGOTA
Affiant

SUBSCRIBED AND SWORN to before me this 20 th day of August, 2019,

at Malolos City, Bulacan, affiant exhibiting to me his Driver’s License No. F07-
07-003473, a competent proof of identity, and known to me and to me known
personally to be the same person who executed the foregoing Affidavit

Doc. No. ___;

Page No. ___;
Book No.___;
Series of 2019.
REPUBLIC OF THE PHILIPPINES )
MALOLOS CITY, BULACAN. . . . . .) S.S.

AFFIDAVIT OF INSURANCE CLAIM

I, ANTHONY BEGOTA, of legal age, married, Filipino and resident of

B24 L35 Bulacan Meadows, Caypombo, Santa Maria, Bulacan, after having
been duly sworn to in accordance with law, do hereby depose and say:

1. That I am the owner of a motor vehicle, more particularly described

as follows:

MAKE/ MODEL COLOR CHASSIS ENGINE PLATE NO.

TYPE
Ford 2016 Mars Red MPBSXXMXK UEJAGK471 NCF 1257
Ecosport SGK47140 40

2. That last July 18, 2019 at around 4:00 in the afternoon, while
maneuvering said vehicle, I accidentally bumped a motorcycle which was
parked at the road side in Caypombo, Santa Maria, Bulacan;

3. That as a result of which my vehicle sustained damage at its left

door, front side;

4. That I am executing this affidavit to attest to the veracity of the facts

contained herein and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 20 th day of

August, 2019 at Malolos City, Bulacan.

ANTHONY BEGOTA
Affiant

SUBSCRIBED AND SWORN to before me this 20 th day of August, 2019,

at Malolos City, Bulacan, affiant exhibiting to me his Driver’s License No. F07-
07-003473, a competent proof of identity, and known to me and to me known
personally to be the same person who executed the foregoing Affidavit

Doc. No. ___;

Page No. ___;
Book No.___;
Series of 2019.
REPUBLIC OF THE PHILIPPINES )
PROVINCE OF BULACAN……….)
CITY OF MALOLOS………….. . . .) S.S.

AFFIDAVIT OF ACCIDENT

I, JEXZEL FLORES JINGCO, of legal age, single, Filipino and with residence and
postal address at Blk 6, Lot 6, Grandtown Village, Sumapang Matanda, Malolos City, Bulacan,
after having been duly sworn to in accordance with law, do hereby depose and say;

That, I am the son of EMERITA F. JINGCO who is the registered owner of a certain
motor vehicle, Honda Mobilio with Plate No. ADJ-9435;

That on March 13, 2019 at about 2:30 to 3:00 PM, while I was driving said motor vehicle
along Fausta Highway, Crossing, Malolos City, when suddenly out of nowhere, a certain
motorcycle hit the right front door and right rim of our said motor vehicle thereby resulting
damages;

That, all effort was exerted by me to locate the owner of said motorcycle who caused the
damage of our car but to no avail; and

That I am executing this affidavit to attest to the veracity of the facts contained herein and
for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 21 st day of March, 2019 at
Malolos City, Bulacan.

JEXZEL FLORES JINGCO

Affiant

SUBSCRIBED AND SWORN to before me this 21 st day of March, 2019, at Malolos

City, Bulacan. in accordance with the 2004 Rules of Notarial Practice, affiant exhibiting to me
his Driver’s License No. C07-12-000208 a competent proof of identity, and known to me and to
me known personally to be the same person who executed the foregoing Affidavit

WITNESS MY HAND AND SEAL.

Notary Public
Doc. No.________;
Page No.________;
Book No._________;
Series of 2019

REPUBLIC OF THE PHILIPPINES)

MALOLOS CITY, BULACAN . . . .) S.S.

AFFIDAVIT OF ACCIDENT

I, RAMONITO C. PEREZ, of legal age, Filipino and resident of Block 25 Lot 12

Maranya St., Maunlad, Malolos City, Bulacan, after having been duly sworn to in accordance
with law, do hereby depose and say:

1. – That I am the authorized driver of a certain motor vehicle, described as follows :

MAKE & TYPE : HYUNDAI GETZ 1.1L M/T

CHASSIS NO. : KMHBT51GAAU971937
MOTOR NO. : G4HGA707745
PLATE NO. : PDO-305

2. – That Antonio H. Agustin, Jr. of 564 Sipat, Plaridel, Bulacan is the is the registered
owner of said motor vehicle;

3. – That sometime on February 6, 2011 at around 5:30 PM I left said motor vehicle
unattended at Malolos Public Market, Malolos City, Bulacan;

4. – That when I came back, I found out that the said motor vehicle sustained damage at
its front bumper, left side tail light and left side bumper;

5. – That nobody noticed who and what caused the damage sustained by the car since the
same was left unattended;

6. – That I am executing this affidavit to attest to the veracity of the facts contained
herein and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 7 th day of February 2011 at
Malolos City, Bulacan.

RAMONITO C. PEREZ
Affiant
Driver’s License No. N01-82-014331

SUBSCRIBED AND SWORN to before me this 7 th day of February, 2011 at Malolos

City, Bulacan.
Doc. No. ___; BERNAR D. FAJARDO
Page No. ___; Notary Public
Book No.___; Until December 31, 2012
Series of 2011. P.T.R. No. 4048722
MCLE II-0019636 12-21-10
Roll No. 33633

REPUBLIC OF THE PHILIPPINES )

MALOLOS CITY, BULACAN. . . . ) S.S.

AFFIDAVIT OF ACCIDENT

I, VICTORINO T. SANTIAGO, of legal age, Filipino and resident of San Agustin,

Hagonoy, Bulacan, after having been duly sworn to in accordance with law, do hereby depose
and say:

1. That I am the registered owner of a motor vehicle, Toyota Sedan with Plate No. PQO-
963;

2. That sometime on March 21, 2014 at I was following a dump truck within Km. 32
South Bond of the North Luzon Expressway and with the territorial jurisdiction of Balintawak, a
stone suddenly and accidentally hit my windshield;

3. That as a result of which, my windshield was damaged;

4. That I am executing this affidavit to attest to the veracity of the facts contained herein
and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 24 th day of March, 2014 at
Malolos City, Bulacan.

VICTORINO T. SANTIAGO
Affiant
Driver’s License No.C07-85-855675

SUBSCRIBED AND SWORN to before me this 24th day of March, 2014 at Malolos
City, Bulacan.

Doc. No. ___; BERNAR D. FAJARDO

Page No.___; Notary Public
Book No. ___; Until December 31, 2014
Series of 2014. PTR No. 0196207 Roll No. 33633
MCLE IV-0002533 8-16-11
REPUBLIKA NG PILIPINAS )
MALOLOS, BULACAN ) S.S.

SINUMPAANG SALAYSAY

Ako si ANTONIO C. DELA ROSA, JR., may sapat na gulang, Pilipino at

naninirahan sa Block 13 Lot 3 Phase 1 Grand Royale Subd., Bulihan, Malolos,
Bulacan, matapos makapanumpa nang naaayon sa batas ay malaya at kusang loob
na dito ay nagpapahayag:

Na ako ang authorized driver sa isang sasakyan na pag-aari ni Helen G.

dela Rosa ng Malolos, Bulacan, ang nasabing sasakyan ay makikilala sa mga
sumusunod na palatandaan:

MAKE & TYPE : TOYOTA WAGON

MOTOR NO. : 2KD-6263662
CHASSIS NO. : KUN40-5028226
PLATE NO. : NLI244

Na noong ika-18 ng Oktubre, 2010 sa Munisipyo ng Calumpit, Bulacan, sa

pagitan ng 5:00 at 5:30 ng hapon habang sa kalakasan ng ulan, ang nasabing
sasakyan ay aking minamani-obra nang ito ay tumama sa unahang bahagi nito
(left side bumper) ang isang kongretong bato at ng ito ay aking iatras, tumama
naman ang nasabing sasakyan sa likurang bahagi nito (right side panel) sa isang
steel sign board;

Na dahil sa nasabing aksidente, ang left side bumper ng nasabing sasakyan

ay nasira o nayupi at ang right side panel ay nagasgas;

Na ginawa ko ang salaysay na ito upang patotohanan ang lahat na dito

nasasaad.

SA KATOTOHANAN NG LAHAT, ako ay lumagda sa ibaba nito ngayong

ika-__ ng Oktubre, 2010, dito sa Malolos, Bulacan.

ANTONIO C. DELA ROSA, JR.

Nagsalaysay
 SINUMPAAN AT NILAGDAAN sa harap ko ngayong ika-__ ng Oktubre,
2010 dito sa Malolos, Bulacan, ang nagsalaysay ay may Driver’s License No.
CO7-98-162623.

Kas. Blg. ___; BERNAR D. FAJARDO

Pah. Blg. ___; Notary Public
Aklat Blg.___; Until December 31, 2010
Taong 2010. P.T.R. No. 1496043 Roll No. 33633
MCLE II-0011645 8-27-08

REPUBLIKA NG PILIPINAS )
MALOLOS, BULACAN ) S.S.

SINUMPAANG SALAYSAY

Ako si AURENZ M. SANTOS, may sapat na gulang, Pilipino at naninirahan sa 151

Sumapang Matanda, Malolos City, Bulacan, matapos makapanumpa nang naaayon sa batas ay
malaya at kusang loob na dito ay nagpapahayag:

Na ako ang nagmamay-ari ng isang sasakyan, makikilala sa mga sumusunod na

palatandaan:

MAKE & TYPE : TOYOTA AVANZA

MOTOR NO. : MD82068
FRAME NO. : MHKM1BF2FBK004550
CONDUCTION NO : YD-2074

Na noong ika-29 ng Agosto 2014 sa loob ng Bulacan State University (BSU), Malolos
City, Bulacan sa pagitan ng 3:30 at 4:00 ng hapon habang minamaneho ang nasabing
sasakyang papanik ako ng rampa ay may tambak na lupa naman ito kaya ako nakapanik ngunit
sa aking pagbaba ay wala palang tambak ang kabilang bahagi kaya humampas ang ilalim na
sasakyan sa rampa;

Na dahil sa nasabing aksidente, ang under cover ng makina ay nagasgas at nasira

naman ang mud guard ng kaliwang bahagi ng harapan ng gulong ng nasabing sasakyan;

Na ginawa ko ang salaysay na ito upang patotohanan ang lahat na dito nasasaad.

SA KATOTOHANAN NG LAHAT, ako ay lumagda sa ibaba nito ngayong ika-15 ng

Setyembre, 2014, dito sa Malolos, Bulacan.

AURENZ M. SANTOS
Nagsalaysay

SINUMPAAN AT NILAGDAAN sa harap ko ngayong ika-15 ng Setyembre, 2010 dito sa

Malolos, Bulacan, ang nagsalaysay ay may Driver’s License No. CO7-12-018275.

Kas. Blg. ___;

Pah. Blg. ___;
Aklat Blg.___;
Taong 2014.
REPUBLIKA NG PILIPINAS )
MALOLOS, BULACAN ) S.S.

SINUMPAANG SALAYSAY

Ako si JOHN JOSHUA T. RAYOS, __, taong gulang, Pilipino at naninirahan

sa _________________________________, matapos makapanumpa nang
naaayon sa batas ay malaya at kusang loob na dito ay nagpapahayag:

Na ako ay Grade 6 pupil ng Malolos Christian School, Malolos City,

Bulacan;

Na noong ika 26 ng Enero, 2011, sa loob ng nasabing paaralan, ako ay

nakikipaglaro sa aking kaklase at isinipa ko ang aking paa sa hangin pero na out
of blance ako at ako ay bumagsak, naitukod ko ang aking kaliwang kamay na
naging dahilan ng pagkakabali ng buto ko sa aking braso;

Na ginawa ko ang salaysay na ito upang patotohanan ang lahat na dito

nasasaad.

SA KATOTOHANAN NG LAHAT, ako ay lumagda sa ibaba nito ngayong

ika-__ ng Pebrero, 2011, dito sa Malolos, Bulacan.

JOHN JOSHUA T. RAYOS

Nagsalaysay
Sa pag-gabay ni:

_______________________
(Pangalan ng Magulang)

SINUMPAAN AT NILAGDAAN sa harap ko ngayong ika-__ ng Pebrero, 2011 sa

Malolos, Bulacan.

Kas. Blg. ___;

Pah. Blg. ___;
Aklat Blg.___;
Taong 2011.
REPUBLIC OF THE PHILIPPINES )
MALOLOS CITY, BULACAN. . . . . . ) S.S.

AFFIDAVIT OF INSURANCE CLAIM

I, MARVIN NAGUIT PINEDA, of legal age, Filipino and resident of 25 E. Mercado St.,
Poblacion, Sto. Tomas, Pampanga, after having been duly sworn to in accordance with law, do
hereby depose and say:

1. – That I am the owner of a motor vehicle, Foton Tornado Dropside with Plate No.
PQH-911;

2. – That, my driver, Rolly B. Calma, while driving said vehicle at Balagtas, Batangas at
around 10:00 in the morning on November 11, 2011, a vehicle accidentally bumped the front
portion of my vehicle wherein the front bumper, horn and the front grills were damaged;

3. – That when he was about to park my vehicle on the shoulder of the road, the vehicle
who bumped the front portion of my vehicle did not stop wherein we was not able to apprehend
the owner of the vehicle;

4. – That I am executing this affidavit to attest to the veracity of the facts contained
herein and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this 18 th day of November, 2011
at Malolos City, Bulacan.

MARVIN NAGUIT PINEDA

Affiant

SUBSCRIBED AND SWORN to before me this 18th day of November, 2011, at Malolos
City, Bulacan. in accordance with the 2004 Rules of Notarial Practice, affiant exhibiting to me
his Driver’s License No.C10-96-128670 a competent proof of identity, and known to me
and to me known personally to be the same person who executed the foregoing Affidavit

WITNESS MY HAND AND SEAL.

Doc. No. 234; BERNAR D. FAJARDO

Page No. 46; Notary Public
Book No. 90 ; Until December 31, 2012
Series of 2011. P.T.R. No. 4048722 Roll No. 33633
MCLE III-0019636 12-21-10
REPUBLIC OF THE PHILIPPINES )
MALOLOS CITY, BULACAN. . . ) S.S.

AFFIDAVIT OF INSURANCE CLAIM

I, GLORIA R. QUIAMBAO, of legal age, Filipino and resident of Pagsibigan St., Sto.
Rosario, Poblacion, Malolos City, Bulacan, after having been duly sworn to in accordance with
law, do hereby depose and say:

1. – That I am the registered owner of a motor vehicle, Mitsubishi Adventure with

Plate No. CTB-780;

2. – That sometime on August 7, 2012, due to severe rainfall caused widespread and deep
flooding in many areas of Bulacan and other places, I parked said vehicle at the parking lot of
Sto. Rosario Church, Sto. Rosario, Malolos City, Bulacan;

3. – That when I came back, I found out that the said motor vehicle sustained damage at
its back door, rear end and back flooring;

4. – That nobody noticed who and what caused the damage sustained by the car since the
same was left unattended;

5. – That I am executing this affidavit to attest to the veracity of the facts contained
herein and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this 10 th day of October, 2012
at Malolos City, Bulacan.

GLORIA R. QUIAMBAO
Affiant

SUBSCRIBED AND SWORN to before me this 10 th day of October, 2012, at Malolos

City, Bulacan, affiant exhibiting to me her CTC No. 36993022 issued at Malolos City,
Bulacan on January 17, 2012, and known to me and to me known personally to be the same
person who executed the foregoing Affidavit.

Doc. No. ___; BERNAR D. FAJARDO

Page No. ___; Notary Public
Book No. 97 ; Until December 31, 2012
Series of 2012. P.T.R. No. 7960111 Roll No. 33633
MCLE IV-0002533 8-16-11
REPUBLIKA NG PILIPINAS )
MALOLOS, BULACAN. . . . . . ) S.S.

SINUMPAANG SALAYSAY

Ako si REYNALDO C. ENRIQUEZ, JR., may sapat na gulang, Pilipino at

naninirahan sa 1377 Rodriguez St., Poblacion, Santa Maria, Bulacan, matapos
makapanumpa nang naaayon sa batas ay malaya at kusang loob na dito ay nagpapahayag:
 1. Na ako ang nagmamay-aring tunay sa isang sasakyan, Mitsubishi Strada Pick-Up
na may Plaka Blg. APA-9149;

2. Na noong ika-17 ng Setyembre, 2016 sa Poblacion, Santa Maria, Bulacan, sa pagitan

ng 8:30 at 9:30 ng gabi habang sa kalakasan ng ulan, ang nasabing sasakyan ay
aking minamaneho upang pumarada nang ako ang paatras ito ay tumama sa
isang konkretong bato at ng ito ay aking iabante ay nasagi ko naman ang isang
konkretong upuan ng isang tindahan;

3. Na dahil sa nasabing aksidente, ang rear bumper, gawing ilalim, left side at front
bumper, left side ay nagkaroon at nagtamo ng gasgas o nasira;

4. Na ginawa ko ang salaysay na ito upang patotohanan ang lahat na dito nasasaad.

SA KATOTOHANAN NG LAHAT, ako ay lumagda sa ibaba nito ngayong ika-24

ng Oktubre, 2016, dito sa Malolos, Bulacan.

REYNALDO C. ENRIQUEZ, JR.

Nagsalaysay
Drivers License No. CO7-06-005312

SINUMPAAN AT NILAGDAAN sa harap ko ngayong ika-24 ng Oktubre, 2016 dito

sa Malolos, Bulacan.

Kas. Blg. ___;

Pah. Blg. ___;
Aklat Blg.___;
Taong 2016.

REPUBLIC OF THE PHILIPPINES )

MALOLOS CITY, BULACAN. . . ) S.S.

AFFIDAVIT

I, CECILIA S. CUSTODIO, of legal age, married, Filipino and resident of San Roque
St., Angat, Bulacan, after having been duly sworn to in accordance with law, do hereby depose
and say:
 1. That I am the registered owner of a certain motor vehicle, more particularly described
as follows:

MAKE & TYPE : TOYOTA VIOS 1.3 A/T

MOTOR NO. : 2N27293312
CHASSIS NO. : NCP151-2030320
PLATE NO. : CN No. YI 9752

2. That on January 8, 2015 at around 5:30 AM, I left said motor vehicle unattended in
front of Angat Public Market, located at Brgy. San Roque, Angat, Bulacan;

3. That when I came back, I found out that the rear bumper of said motor vehicle
sustained damage;

4. That nobody noticed who and what caused the damages sustained by the car since the
same was left unattended;

5. That I am executing this affidavit to attest to the veracity of the facts contained herein
and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this 2 nd day of February, 2015
at Malolos City, Bulacan.

CECILIA S. CUSTODIO
Affiant

SUBSCRIBED AND SWORN to before me this 2 nd day of February, 2015, at Malolos

City, Bulacan, affiant exhibiting to me her Driver’s License No. C07-14-023083, a competent
proof of identity, and known to me and to me known personally to be the same person who
executed the foregoing Affidavit

Doc. No. ___; JOSE M. CASTRO

Page No. ___; Notary Public
Book No. XXX; Until December 31, 2015
Series of 2015. PTR No. 1791340 Roll No. 16895
MCLE IV-0002542 8/16/11

REPUBLIC OF THE PHILIPPINES )

MALOLOS CITY, BULACAN. . . ) S.S.

AFFIDAVIT OF INSURANCE CLAIM

I, GUO, ZHEN YONG of legal age, Chinese National and resident of Ph1B B5 L8,
Grand Royale Subd., Malolos City, Bulacan, after having been duly sworn to in accordance with
law, do hereby depose and say:

1. That I am the authorized driver of a certain motor vehicle, more particularly described
as follows:

MAKE & TYPE : BMW X3 XDRIVE 2.0D Executive

MOTOR NO. : 74037552N47D20C
CHASSIS NO. : WBAWY31080L521384
 PLATE NO. : TJQ-558

2. That last night, November 14, 2013 at around 8:30 PM, while driving said vehicle I
accidentally bumped the concrete post in our garage;

3. That as a result of which the front right bumper of my said vehicle sustained damage
and its right headlight was not functioning;

4. That I am executing this affidavit to attest to the veracity of the facts contained herein
and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 15th day of November, 2013
at Malolos City, Bulacan.

GUO, ZHEN YONG

Affiant

SUBSCRIBED AND SWORN to before me this 15 th day of November, 2013, at Malolos

City, Bulacan, affiant exhibiting to me his Driver License No. C07-05-011303, competent proof
of identity, and known to me and to me known personally to be the same person who executed
the foregoing affidavit.

WITNESS MY HAND AND SEAL.

Doc. No. ___; BERNAR D. FAJARDO

Page No.___; Notary Public
Book No. ___; Until December 31, 2014
Series of 2013. P.T.R. No. 9473699 Roll No. 33633
MCLE IV-0002533 8-16-12

That sometime on Nov. 15, 2002 my friend Jose requested me to accompany him to San
Fernando City, Pampanga;

That on our way to our destination or while within the vicinity of United Pulp and Paper
Co. (UPPC), Brgy. Palimbang, Calumpit, Bulacan a male person later on identified as Edilberto
Dizon was accidentally hit by the vehicle being driven my Jose;

That the incident happened when Edilberto alighted from FX Tamaraw suddenly crossed
to the opposite side of the road. Apparently, Edilberto was confused because he was rattled by a
jeepney which was tailing the FX Tamarraw;

That immediately after the incident, Jose and myself brought Edilberto to the nearest
hospital, Calumpit District Hospital, where he was given first aid treatment and later on to the
Bulacan Provincial Hospital in Malolos City, Bulacan for further medical treatment;

That in connection with the incident, I earlier gave my statement before the Investigator
of Criminal Investigation Service at Malolos City. A copy of which is hereto attached and made
an integral part hereof.
REPUBLIC OF THE PHILIPPINES )
MALOLOS CITY, BULACAN. . . . ) S.S.

AFFIDAVIT
I, RYAN OLIVER LIM, of legal age, Canadian National and resident of 20 Flicker St.,
Greenmeadows, Quezon City, after having been duly sworn to in accordance with law, do hereby
depose and say:

1. That I am the owner of a motor vehicle, BMW 525i Sedan, 1992 Model with Plate
No. UUC-313;

2. That while I was driving said vehicle along Paranaque City, at around 4:45 in the
afternoon on March 30, 2014, a vehicle (Mitsubishi Montero) with Plate No. NDO-421,
accidentally bumped the rear portion of my vehicle wherein the rear bumper was damaged;

3. That when I parked my vehicle on the shoulder of the road, I noticed the owner of
vehicle, Mitsubishi Montero who bumped the rear portion of my vehicle is JOHN LEO S.
ZULUETA, of Sumapang Matanda, Malolos City, Bulacan;

4. That I am executing this affidavit to attest to the veracity of the facts contained herein
and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this 8 th day of May, 2014 at
Malolos City, Bulacan.

RYAN OLIVER LIM

Affiant

SUBSCRIBED AND SWORN to before me this 8 th day of May, 2014, at Malolos City,
Bulacan. in accordance with the 2004 Rules of Notarial Practice, affiant exhibiting to me his
Driver’s License No.__________, a competent proof of identity, and known to me and to me
known personally to be the same person who executed the foregoing Affidavit
 WITNESS MY HAND AND SEAL.

Doc. No. ___; BERNAR D. FAJARDO

Page No. ___; Notary Public
Book No.111 ; Until December 31, 2014
Series of 2014. PTR No. 0196207 Roll No. 33633
MCLE IV-0002533 8-16-11

PAGPAPATUNAY

Kami po sina, AXEL B. DOMINGO at ALORD IVAN B. DOMINGO, 14 at 13, taong

gulang, at nagsisipanirahan sa Brgy. Capalangan, Apalit, Pampanga, ay kusang loob na –

NAGPAPATUNAY at NAGSASAYSAY:

Na, kilala namin si EMILIO D. ABAC, a.k.a. Emil sapagkat siya ay aming kaibigan;

Na noong Hulyo 28, 2014 mga bandang alas 3:30 ng hapon, humigit-kumulang,
nanonood kami noon ng larong basketball sa aming barangay sa Capalangan, Apalit, Pampanga,
at isa si Emilio D. Abac sa mga naglalaro ng basketball;

Na, sa kanyang paglalaro ay nag-dunk si Emilio D. Abac at nakita namin kung paanong
biglang naputol ang pinaka-poste ng board at bumagsak ito sa likod ni Emilio D. Abac at
padausdos itong dumiretso sa kaliwang paa niya;

Na, nagkagulo ang mga tao dahil sa nangyaring aksidente kay Emilio Abac at napag-
alaman namin na marupok na pala ang nasabing post ng board dahil na rin sa may katagalan na
at luma na ito;

Na, dinala ito sa ospital at dahil sa nangyari ay kailangang operahan ang kaliwang paa ni
Emilio Abac; at

Na, aming isinagawa ang salaysay na ito upang patotohanan ang mga bagay na nabanggit
sa dakong itaas nito.

SA KATUNAYAN NG LAHAT, kami ay lumagda sa ibaba nito ngayong ika-28 ng

Agosto, 2014, sa Malolos, Bulacan.

AXEL B. DOMINGO ALORD IVAN B. DOMINGO

Nagsalaysay Nagsalaysay

NILAGDAAN SA HARAP NINA:

1. _____________________________ 2. __________________________
REPUBLIKA NG PILIPINAS )
MALOLOS, BULACAN. . . ) S.S.

SA HARAP KO, na isang Notaryo Publiko sa Lalawigan ng Bulakan, ngayong ika-28 ng

Agosto, 2014 ay dumulog sina: AXEL B. DOMINGO at ALORD IVAN B. DOMINGO na
kilala kong silang gumawa ng kasulatang ito gayundin ang kanilang mga saksi at kilala ko sila
dahil sa paglagda nila sa kasulatang ito at pagpapatibay sa harap ko na ang gayon ay tunay at
malaya nilang kapasiyahan.

SAKSI ANG AKING LAGDA AT TATAK PANGNOTARYO.

Kas. Blg. ____; BERNAR D. FAJARDO

Pah. Blg. ____; Notary Public
Aklat Blg.____; Hanggang Disyembre 31, 2014
Taong 2014. PTR Blg. 0196207 Roll No. 33633
MCLE IV-0002533 8-16-11

REPUBLIKA NG PILIPINAS )
MALOLOS, BULACAN ) S.S.

SINUMPAANG SALAYSAY

Ako, si ANNALIZA L. DE GUZMAN, may sapat na gulang, may-asawa, Pilipino at

naninirahan sa Golden Grain Villas, Mojon, Malolos City, Bulacan, matapos makapanumpa
nang naaayon sa batas ay malaya at kusang loob na dito ay nagpapahayag:

Na ako ang pinapahintulang magmaneho/magdala ng isang sasakyan, na pag-aari ng

aming kumpanya, Bayer Philippines, Inc., makikilala sa mga sumusunod na palatandaan:

MAKE & TYPE: Honda City Sedan

MOTOR NO. : L13Z12407279
CHASSIS NO. : PADGM151DAV100804
PLATE NO. : NOJ-349

Na noong ika-11 ng Agosto, 2014 sa Baliuag, Bulacan, sa pagitan ng 3:30 at 4:30 ng

hapon habang sa kalakasan ng ulan, ang nasabing sasakyan ay aking minamaneho nang ito ay
tumama sa isang konkretong poste;

Na dahil sa nasabing aksidente, ang kanang bahagi ng pinto (passenger’s side) ay

nagkaroon ng sira o malalim na dent at sa bandang ilalim ng sasakyan ay nagkaroon din ng
gasgas ;

Na ginawa ko ang salaysay na ito upang patotohanan ang lahat na dito nasasaad.

SA KATOTOHANAN NG LAHAT, ako ay lumagda sa ibaba nito ngayong ika-29 ng

Agosto, 2014, dito sa Malolos, Bulacan.

ANNALIZA DE GUZMAN
Nagsalaysay
Drivers License No. CO7-04-250462

SINUMPAAN AT NILAGDAAN sa harap ko ngayong ika-29 ng Agosto, 2014 dito sa

Malolos, Bulacan.

Kas. Blg. ___;

Pah. Blg. ___;
Aklat Blg.___;
Taong 2014.

REPUBLIC OF THE PHILIPPINES )

MALOLOS CITY, BULACAN. . . . . . ) S.S.

AFFIDAVIT

I, ALFREDO B. MAROMA, JR., of legal age, married, Filipino and resident of 3156
San Pablo, Malolos City, Bulacan, after having been duly sworn to in accordance with law, do
hereby depose and say:

1. That I am the owner of a motor vehicle, Mitsubishi Lancer with Plate No.RBE-278;

2. That yesterday, September 17, 2014 at around 9:45 in the morning at Dakila, Malolos,
Bulacan, while maneuvering said vehicle, I accidentally bumped another vehicle;

3. That as a result of which the rear bumper (right side) of my said vehicle sustained
damage;

4.– That I am executing this affidavit to attest to the veracity of the facts contained herein
and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this 18 th day of September,

2014 at Malolos City, Bulacan.

ALFREDO B. MAROMA, JR.

Affiant

SUBSCRIBED AND SWORN to before me this 18 th day of September, 2014, at Malolos

City, Bulacan. in accordance with the 2004 Rules of Notarial Practice, affiant exhibiting to me
his UMID ID No. 004-0012-4874-2, a competent proof of identity, and known to me and to me
known personally to be the same person who executed the foregoing Affidavit

WITNESS MY HAND AND SEAL.

Doc. No. ___; BERNAR D. FAJARDO

Page No.___; Notary Public
Book No. ___; Until December 31, 2014
Series of 2014. P.T.R. No. 0196207 Roll No. 33633
MCLE IV-0002533 8-16-11

REPUBLIC OF THE PHILIPPINES )

MALOLOS CITY, BULACAN. . . . . . ) S.S.

AFFIDAVIT

I, MA. VICTORIA V. CONSTANTINO, of legal age, married, Filipino and resident of

San Agustin, Hagonoy, Bulacan, after having been duly sworn to in accordance with law, do
hereby depose and say:

1. That I am a duly licensed driver with Driver’s License No. C07-08-006120 covered
by DLR SM Pampanga No. 0382, which is valid until December 24, 2015;

2. That on September 5, 2015, at around 10 o’clock in the morning, when I switch on to

heat up a motor vehicle owned and registered in my name which is more particularly described
as follows:

MAKE & TYPE : Mitsubishi Wagon

MOTOR NO. : 4D56AAJ6842
CHASSIS NO. : PAEVB5NHEEB006837
PLATE NO. : AAB 8729

3. That when I switched on I did not noticed that the shifting gear was not on neutral
position thus as the engine come alive it automatically move on the driveway toward the terrace
on my sister-in-law which is right in front of our garage my car collided with side wall of the
front terrace and as a result the said vehicle sustained damage at its right side mirror totally
broke off from its connection, scratches on right fender, scratches on left and right side of
front bumper, scratches on front bumper with a slight bent under pushing the bumper
slight down as it came of its clip;

4. That I am executing this affidavit to attest to the veracity of the facts contained herein
and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this 8 th day of September

2015 at Malolos City, Bulacan.

MA. VICTORIA V. CONSTANTINO

Affiant

SUBSCRIBED AND SWORN to before me this 8 th day of September, 2015, at Malolos

City, Bulacan, affiant exhibiting to me his Driver’s License No. C07-08-006120, a competent
proof of identity, and known to me and to me known personally to be the same person who
executed the foregoing Affidavit

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2015.

REPUBLIKA NG PILIPINAS )
MALOLOS, BULACAN ) S.S.

SINUMPAANG SALAYSAY
 Ako, si DANILO HALILI, may sapat na gulang, may-asawa, Pilipino at naninirahan sa
Calumpang, Calumpit, Bulacan, matapos makapanumpa nang naaayon sa batas ay malaya at
kusang loob na dito ay nagpapahayag:

Na ako ang pinapahintulang magmaneho/magdala ng isang sasakyan, na pag-aari ni

JESUSA PEREZ NUCUM ng Phase 8B, Blk. 9 Lot 19 Grand Royale Subd., Bulihan, Malolos,
Bulacan, makikilala sa mga sumusunod na palatandaan:

MAKE & TYPE : TOYOTA VIOS 1.5 GAS A/T

MOTOR NO. : INZ-Z100341
CHASSIS NO. : NCP150-2004084
PLATE NO. : ABB-4712

Na noong ika-20 ng Setyembre, 2015 sa Calumpang, Calumpit, Bulacan sa pagitan ng

7:30 at 8:00 ng gabi habang minamane-obra ko ang nasabing sasakyan ito ay tumama sa isang
konkretong bato, dahil duon ang nasabing sasakyan ay nagkaroon ng gasgas/nasira sa may
likurang bahagi (left rear bumper) at ibabang kanang bahagi ng compartment;

Na ginawa ko ang salaysay na ito upang patotohanan ang lahat na dito nasasaad.

SA KATOTOHANAN NG LAHAT, ako ay lumagda sa ibaba nito ngayong ika-21 ng

Setyembrre, 2015, dito sa Malolos, Bulacan.

DANILO HALILI
Nagsalaysay
Drivers License No. C07-12-012232

SINUMPAAN AT NILAGDAAN sa harap ko ngayong ika-20 ng Setyembre 2015 dito sa

Malolos, Bulacan.

Kas. Blg. 43;

Pah. Blg. 10;
Aklat Blg.37;
Taong 2015.

REPUBLIC OF THE PHILIPPINES

PROVINCE OF BULACAN S.S.
MALOLOS CITY

AFFIDAVIT
 I, RONWALDO MIRANDA TARUC, of legal age, Filipino, married, and a
resident of B17 L16 PH3 St. Agatha, Brgy. Tikay, Malolos City, Bulacan after having
been duly sworn to in accordance with law, do hereby deposes and states:

1. That I met an accident on September 3, 2015 at around 3:00pm while I was

driving my Toyota Avanza with plate no. ULI 819;

2. That on said date and time, I was travelling along Brgy. San Francisco, Bulakan,
Bulacan when suddenly a pedestrian crossed my path and to avoid hitting him I
swerved immediately to the right;

3. That upon swerving I bumped a solid fence causing extensive damage to my car;

4. The damage is estimated to be in the amount of P392,350.00 evidenced by an

estimate from Toyota Motors Plaridel, Bulacan Branch.

5. That undersigned voluntarily executes this Affidavit for the purpose of insurance
claims 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 ___ of September

2015, hereat Malolos City, Bulacan.

RONWALDO MIRANDA TARUC

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME by the affiant and that above Affidavit is executed
voluntarily and by his own free will, this ___ of September 2015, hereat Malolos City, Bulacan.

NOTARY PUBLIC

REPUBLIC OF THE PHILIPPINES )

PROVINCE OF BULACAN……….) S.S.
MUNICIPALITY OF MALOLOS… )

AFFIDAVIT OF INSURANCE CLAIM

I, MARIA LOURDES PAGDANGANAN, of legal age, Filipino and with postal address
at Capalangan, Apalit, Pampanga, after having been duly sworn to in accordance with law,
hereby depose and say:
 1. That, I am the authorized driver of a certain motor vehicle which is owned by Jona
Jean P. Armas, more particularly described as follows:

Make & Type…………………….. Toyota Fortuner 4x2 2. SUV

Motor No…………………………. 2KDU631827
Serial/Chassis No…………………MHFZR89G803106837
Plate No……………………………AMA-3802
MV File No…………………………038000000222101

2. That on January 27, 2016 at around 8:30 o’clock in the evening, I parked said vehicle
at the parking area of SM Pampanga located at San Fernando, Pampanga;

3. That when I came back, I found out that SPARE TIRE of said vehicle was missing;

4. That, despite diligent and earnest effort exerted to locate said SPARE TIRE, the same
has been proven futile and is now beyond recovery; and

5. That, I am executing this affidavit in order to establish and affirm the truths of the
foregoing, and, for all legal intents and purposes.

IN WITNESS WHEREOF, I have hereunto affixed my signature this __ day of

February, 2016 at Malolos City, Bulacan.

MARIA LOURDES PAGDANGANAN

Affiant

SUBSCRIBED AND SWORN TO before me, this __ day of February, 2016 at Malolos
City, Bulacan, affiant exhibited to me her Driver’s License No. _________________, a
competent of identity, and known to me and to me known personally to be the same person who
executed the foregoing Affidavit.

Doc. No. ___;

Page No.___;
Book No. ___;
Series of 2016.

REPUBLIC OF THE PHILIPPINES

PROVINCE OF BULACAN S.S.
MALOLOS CITY

AFFIDAVIT
I, FERNANDO M. BIGORNIA, of legal age, Filipino, married, and a
resident of 120 Pearl Drive, St. Francis Subd., Pandayan, Meycauayan, Bulacan,
after having been duly sworn to in accordance with law, do hereby deposes
and states:

1. That I met an accident on March 26, 2016 at around 10:30AM while I

was driving my Isuzu Pick-Up with Plate No. NOZ-708;
 2. That on said date and time, I was travelling along Rizal Avenue (in front
SM Hypermart), another vehicle, Honda Fit Hatchback with Plate No.
BEX 727 was traveling along Trese Martires Street;

3. That when I was making my way into the outer portion of the road, the
other vehicle (Honda Fit Hatchback) was simultaneously turning right
into Rizal Avenue;

4. That the two vehicles accidentally collided due to our simultaneously

conflicting actions;

5. That as a result of the collision, the Isuzu Pick-Up incurred damages to

its rear side body, bent rear bumper and mis operation of the reverse
sensor;

6. That undersigned voluntarily executes this Affidavit for the purpose of

insurance claims 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 29th of

March 2016, hereat Malolos City, Bulacan.

FERNANDO M. BIGORNIA
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this 29 th day of March, 2016

at Malolos City, Bulacan.

Doc. No. ___;

Page No. ___;
Book No.___;
Series of 2016.
REPUBLIC OF THE PHILIPPINES )
MALOLOS CITY, BULACAN. . . . . ) S.S.

AFFIDAVIT

I, JAYVEE S. BERNAL, of legal age, single, Filipino and resident of Purok 1,

Abulalas, Hagonoy, Bulacan, after having been duly sworn to in accordance with law, do
hereby depose and say:

1. That, I am the authorized driver of a certain motor vehicle which is owned by

my mother Bessie Santos Bernal, more particularly described as follows:

MAKE & TYPE : Toyota Vios 1.3E Gas AT

MOTOR NO. : 2NZ7719313
CHASSIS NO. : NCP1512059856
Conduction No. : YV 3455

2. That on June 28, 2017 at around 7:00 o’clock in the evening, I parked said
vehicle at the parking lot of our dormitory located at Bagong Ilog, Pasig City;
 3. That when I came back, I found out that the said motor vehicle sustained
damage at its left rear door/fender and rear right fender;

4. That nobody noticed who and what caused the damage sustained by the car
since the same was left unattended;

5. That I am executing this affidavit to attest to the veracity of the facts contained
herein and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this 4 th day of July, 2017
at Malolos City, Bulacan.

JAYVEE S. BERNAL
Affiant

SUBSCRIBED AND SWORN to before me this 4th day of July, 2017, at Malolos City,
Bulacan, affiant exhibiting to me his Drivers License No. C10-12-020694, and known to
me and to me known personally to be the same person who executed the foregoing
Affidavit.

REPUBLIC OF THE PHILIPPINES

PROVINCE OF BULACAN S.S.
MALOLOS CITY

AFFIDAVIT

I, RUSSEL JOHN B. GALVEZ, of legal age, single, Filipino and resident

of Block 11 Lot 1 Menzyland Subd., Mojon, City of Malolos, Bulacan, after
having been duly sworn to in accordance with law, do hereby depose and say:

1. That, I am duly licensed driver with a Non-Professional Driver’s

License No. C07-17-008584 which is valid until April 14, 2021;

2. That I am the driver of a motor vehicle which is more particularly

described as follows:

MAKE & TYPE MODE MOTOR NO. CHASSIS NO. PLATE NO.
L
NISSAN NAVARA PICK- 2017 YD25713361T MNTCC2D23Z0 OY 2257
UP 022245
 3. That on January 23, 2019 at around 8:00 o’clock in the evening, I
parked said vehicle at the Parking lot of City Walk, Catmon, Malolos City
Bulacan;

4. That when I came back, I found out that the said motor vehicle
sustained damage at its left tail light and rear bumper;

5. That nobody noticed who and what caused the damage sustained by
the car since the same was left unattended;

6. That I am executing this affidavit to attest to the veracity of the facts

contained herein and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this 28 th day of

January, 2019 at Malolos City, Bulacan.

RUSSEL JOHN B. GALVEZ

Affiant

SUBSCRIBED AND SWORN to before me this 28 th day of January, 2019,

at Malolos City, Bulacan, affiant exhibiting to me his Non-Professional Drivers
License No. C07-17-008584, and known to me and to me known personally to
be the same person who executed the foregoing Affidavit.

Doc. No. 256;

Page No. 53;
Book No. 46;
Series of 2019.

REPUBLIC OF THE PHILIPPINES

PROVINCE OF BULACAN S.S.
MALOLOS CITY

AFFIDAVIT

I, PAULINO P. MALANG, of legal age, Filipino, single, and a resident of 120 Sacdalan,
San Miguel, Bulacan after having been duly sworn to in accordance with law, do hereby deposes
and states:

1. That I met an accident on March 15, 2016 at around 8:00pm while I was driving my
Toyota Fortuner with conduction no. YU 7512;
 2. That on said date and time, I was travelling along Brgy. Tiaong, Baliuag, Bulacan when
suddenly a pedestrian crossed my path and to avoid hitting him I swerved immediately to
the right;

3. That upon swerving I bumped a water meter causing extensive damage (right side
bumper) to my car;

4. That as a consequence of which, the tail light

also sustained damage when a tricycle suddenly hit the rear portion (left side) of my car
causing said damage;

5. That the tricycle who bumped the rear portion of my vehicle did not stop wherein I was
not able to apprehend the owner of the vehicle;

6. That undersigned voluntarily executes this Affidavit for the purpose of insurance claims
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 25 th of May 2016,

hereat Malolos City, Bulacan.

PAULINO P. MALANG
Affiant
Driver’s License No. C07-07-003959

REPUBLIC OF THE PHILIPPINES

PROVINCE OF BULACAN S.S.
MALOLOS CITY

AFFIDAVIT

I, RENATO M. CASTILLO, of legal age, married, Filipino, and a resident

of 176 Camua St., Barangay Sta. Ines, Plaridel, Bulacan, after having been
duly sworn to in accordance with law, do hereby deposes and states:

1. That yesterday, March 11, 2019, I met an accident at around 2:00PM

while I was driving my Toyota Rush with Conduction Sticker No.
A9X595;

2. That on said date and time, while maneuvering said vehicle, at the
parking lot of Primark, Plaridel, Bulacan, I accidentally hit the plant
box;
 3. That as a consequence of which, the right side running board of said
vehicle sustained damage;

4. That undersigned voluntarily executes this Affidavit for the purpose of

insurance claims 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 12 th day

of March 2019, hereat Malolos City, Bulacan.

RENATO M. CASTILLO
Affiant

SUBSCRIBED AND SWORN to before me this 12 th day of March, 2019,

at Malolos City, Bulacan, affiant exhibiting to me his Drivers License No. C07-
96-131192, and known to me and to me known personally to be the same
person who executed the foregoing Affidavit.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2019.

REPUBLIC OF THE PHILIPPINES )

MALOLOS CITY, BULACAN. . . . . ) S.S.

AFFIDAVIT OF ACCIDENT

I, MA. CHRISTINA C. CRUZ, of legal age, Filipino, single, and a resident of Block
30 Lot 41 J. Luna, cor. G. del Pilar, Longos, Malolos City, Bulacan, after having been duly
sworn to in accordance with law, do hereby deposes and states:
 1. That I met an accident on October 30, 2016 at around 1:00PM while I was driving a
motor vehicle (Mazda3 SDN 1.5) with Plate No. ACM 5424 which is owned by my
brother John Paul C. Cruz;

2. That on said date and time, I was travelling along Brgy. Bulusan, Calumpit,
Bulacan when suddenly a pedestrian crossed my path and to avoid hitting him I
swerved immediately to the right;

3. That upon swerving I bumped a sidecar causing extensive damage (front bumper
and right side fender) to my car;

4. That undersigned voluntarily executes this Affidavit for the purpose of insurance
claims 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 4 th of November

2016, hereat Malolos City, Bulacan.

MA. CHRISTINA C. CRUZ

Affiant

SUBSCRIBED AND SWORN to before me this 4 th day of November, 2016, at

Malolos City, Bulacan, affiant exhibiting to me her Temporary Drivers License No.
C1016011564, and known to me and to me known personally to be the same person who
executed the foregoing Affidavit.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2016.

REPUBLIC OF THE PHILIPPINES )

MALOLOS CITY, BULACAN. . . . . ) S.S.

AFFIDAVIT OF ACCIDENT

I, CECILIA N. GASCON, of legal age, Filipino, married, and a resident of Lucban,

Quezon, after having been duly sworn to in accordance with law, do hereby deposes and
states:
 1. That I met an accident on December 30, 2016 at around 8:00PM while I
was driving a motor vehicle (Toyota Altis) with Plate No. PYO 407;

2. That on said date and time, I was travelling along Jamboree Road, going
to University of the Philippines, Los Baños Campus when suddenly a
pedestrian crossed my path and to avoid hitting him I swerved
immediately to the right;

3. That upon swerving I bumped a wood fences causing extensive damage

(head light and scratches) to my car;

4. That undersigned voluntarily executes this Affidavit for the purpose of

insurance claims 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 6 th of January

2017, hereat Malolos City, Bulacan.

CECILIA N. GASCON
Affiant

SUBSCRIBED AND SWORN to before me this 6 th day of January, 2017, at Malolos

City, Bulacan, affiant exhibiting to me her Drivers License No. ________________, and
known to me and to me known personally to be the same person who executed the
foregoing Affidavit.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2017.

REPUBLIC OF THE PHILIPPINES )

MALOLOS CITY, BULACAN. . . . . . ) S.S.

AFFIDAVIT OF ACCIDENT

I, AUDIE EXITO DEPOSITARIO, of legal age, married, Filipino and resident of

Blk. 11 Lot 5 & 7 Mayabong St., Maunlad Homes, Mojon, Malolos City, Bulacan, after
having been duly sworn to in accordance with law, do hereby depose and say:
 1. That I am the registered owner of a motor vehicle, more particularly
described as follows:

MAKE & TYPE : Toyota Fortuner 4x2 2.

MOTOR NO. : 2KDU623835
CHASSIS NO. : MHFZR69G803107543
PLATE NO. : AAV-1654

2. That while I was driving said vehicle at McArthur Highway, Dakila, Malolos
City at around 4:00 o’clock in the afternoon on January 5, 2017, a motorcycle accidentally
bumped the right side of my vehicle wherein the rear door, rear door flare and plate
were damaged;

3. That when I was about to park my vehicle on the shoulder of the road, the
motorcycle who bumped the right side of my vehicle did not stop wherein I was not able
to apprehend the owner of the motorcycle;

4. That I am executing this affidavit to attest to the veracity of the facts contained
herein and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this 6 th day of January,

2017 at Malolos City, Bulacan.

AUDIE EXITO DEPOSITARIO

Affiant

SUBSCRIBED AND SWORN to before me this 6 th day of January, 2017, at Malolos

City, Bulacan, affiant exhibiting to me his Driver’s License No. C07-93086215, a
competent proof of identity, and known to me and to me known personally to be the
same person who executed the foregoing Affidavit

WITNESS MY HAND AND SEAL.

Doc. No. ___;

Page No. ___;
Book No. 13 ;
Series of 2017.

REPUBLIC OF THE PHILIPPINES )

MALOLOS CITY, BULACAN. . . . . ) S.S.

AFFIDAVIT OF ACCIDENT
 I, PETER CHARLES DJ. FAUSTINO, of legal age, married, Filipino and a resident
of #075 Purok 3, Iba O’Este, Calumpit, Bulacan, after having been duly sworn to in
accordance with law, do hereby deposes and states:

1. That I met an accident on February 2, 2019 at around 2:00 PM while I was driving
a motor vehicle, more particularly described as follows:

Make/Type MO CHASSIS NO. ENGINE NO. PLATE NO.

DEL
Mitsubishi Mirage G4 GLX 2016 MMBSTA13AG 3A92UCY7391 ACM 3789
H004122

2. That on said date and time, I was entering to the right of the Crabilicious Sea
Foods Restaurant parking lot when the bumper of my vehicle hit the pavement
whose height was more than the bumper’s height;

3. That upon hitting, the bumper scraped into the pavement causing damage in the
lower portion of my car;

4. That undersigned voluntarily executes this Affidavit for the purpose of insurance
claims 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 14 th of February

2019, hereat Malolos City, Bulacan.

PETER CHARLES DJ. FAUSTINO

Affiant

SUBSCRIBED AND SWORN to before me this 14 th day of February, 2019, at Malolos

City, Bulacan, affiant exhibiting to me his Drivers License No. C07-15-015049, and
known to me and to me known personally to be the same person who executed the
foregoing Affidavit.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2019.

REPUBLIC OF THE PHILIPPINES )

MALOLOS CITY, BULACAN. . . . . ) S.S.
 AFFIDAVIT OF ACCIDENT

I, LEMUEL P. DEL ROSARIO, of legal age, married, Filipino and a resident of

Caniogan, Malolos City, Bulacan, after having been duly sworn to in accordance with law,
do hereby deposes and states:

1. That I met an accident on January 4, 2018 at around 7:00 PM while I was driving a
motor vehicle (Toyota Wigo G) with Conduction VX 2403;

2. That on said date and time, I was exiting to the left of our garage in Caniogan,
Malolos City, Bulacan amidst rainfall and tinted windows were closed when the
side of the vehicle hit the concrete post of the garage;

3. That upon hitting, the side of my car scraped into the post causing damage (rear
left door) to my car;

4. That undersigned voluntarily executes this Affidavit for the purpose of insurance
claims 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 8 th of January

2018, hereat Malolos City, Bulacan.

LEMUEL P. DEL ROSARIO

Affiant

SUBSCRIBED AND SWORN to before me this 8 th day of January, 2018, at Malolos

City, Bulacan, affiant exhibiting to me his Drivers License No. C1114000009, and known
to me and to me known personally to be the same person who executed the foregoing
Affidavit.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2018.

REPUBLIC OF THE PHILIPPINES )

MALOLOS CITY, BULACAN. . . . . ) S.S.

AFFIDAVIT OF ACCIDENT

I, LEMUEL P. DEL ROSARIO, of legal age, married, Filipino and a resident of

Caniogan, Malolos City, Bulacan, after having been duly sworn to in accordance with law,
do hereby deposes and states:

1. That I met an accident on March 3, 2018 at around 3:00 PM while I was driving a
motor vehicle (Toyota Wigo G) with Conduction VX 2403;

2. That on said date and time, I was driving along Concepcion, Baliuag, Bulacan in a
narrow street when, in order to avoid oncoming traffic counter-flow, I swerved to
the right;

3. That upon serving, the side of the vehicle grazed a concrete post causing damage
(front and rear right doors) to my car;

4. That undersigned voluntarily executes this Affidavit for the purpose of insurance
claims 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 28 th of March

2018, hereat Malolos City, Bulacan.

LEMUEL P. DEL ROSARIO

Affiant

SUBSCRIBED AND SWORN to before me this 28 th day of March, 2018, at Malolos

City, Bulacan, affiant exhibiting to me his Drivers License No. C1114000009, and known
to me and to me known personally to be the same person who executed the foregoing
Affidavit.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2018.

REPUBLIC OF THE PHILIPPINES )

MALOLOS CITY, BULACAN. . . . . . . . ) S.S.

AFFIDAVIT OF ACCIDENT

I, ERWIN D. CRUZ, of legal age, married, Filipino and resident of 9019 Looban
St., Pinagbakahan, Malolos City, Bulacan, after having been duly sworn to in accordance
with law, do hereby depose and say:

1. That I am the authorized driver of a motor vehicle, more particularly

described as follows:

MAKE & TYPE : TOYOTA VIOS 1.3E T 4DR SEDAN

MOTOR NO. : 2NZ7504135
CHASSIS NO. : 2CP1512044550
PLATE NO. : YP 2436

2. That while I was driving said vehicle in Agnaya, Plaridel, Bulacan at around 1:00
o’clock in the afternoon on October 15, 2017, a passenger jeep accidentally bumped the
right side of said vehicle wherein the front right side door and head light were
damaged;

3. That when I was about to park my vehicle on the shoulder of the road, the
passenger jeep who bumped the right side of my vehicle did not stop wherein I was not
able to apprehend the owner of the jeep;

4. That I am executing this affidavit to attest to the veracity of the facts contained
herein and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this 27 th day of October,

2017 at Malolos City, Bulacan.

ERWIN D. CRUZ
Affiant

SUBSCRIBED AND SWORN to before me this 27th day of October, 2017, at Malolos
City, Bulacan, affiant exhibiting to me his Driver’s License No. _____________, a
competent proof of identity, and known to me and to me known personally to be the
same person who executed the foregoing Affidavit

WITNESS MY HAND AND SEAL.

Doc. No. ___;

Page No. ___;
Book No. 25 ;
Series of 2017.
REPUBLIC OF THE PHILIPPINES )
MALOLOS CITY, BULACAN. . . . . ) S.S.

AFFIDAVIT OF ACCIDENT

I, CHELSEA BIANCA R. FLORES, of legal age, married, Filipino and a

resident of Km. 56 Flores Compound, Sampaga, San Vicente, Apalit,
Pampanga, after having been duly sworn to in accordance with law, do hereby
deposes and states:

1. That I met an accident on March 20, 2018 at around 9:00 PM while I

was driving a motor vehicle registered in the name of my brother William
Bill DG. Rumingan, more particularly described as follows:

MAKE & TYPE : TOYOTA FORTUNER 4X2 2. SUV

MOTOR NO. : 2KDU445513
CHASSIS NO. : MHFZR69G603083856
PLATE NO. : AAB-2501

2. That on said date and time, I was exiting to the right of our garage in San
Vicente, Apalit, Pampanga amidst rainfall and tinted windows were
closed when the side of the vehicle hit the concrete post of the garage;

3. That upon hitting, the side of my car scraped into the post causing
damage to my car;

4. That undersigned voluntarily executes this Affidavit for the purpose of

insurance claims 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 6 th of

June 2018, hereat Malolos City, Bulacan.

CHELSEA BIANCA R. FLORES

Affiant
REPUBLIC OF THE PHILIPPINES )
MALOLOS CITY, BULACAN. . . . . .) S.S.

AFFIDAVIT OF ACCIDENT

I, JOSELINE M. SANTOS, of legal age, Filipino and resident of

Northfields Subd., Longos, Malolos City, Bulacan, after having been duly
sworn to in accordance with law, do hereby depose and say:

1. That I am the authorized driver of a certain motor vehicle owned and

registered in the name of my husband Mark Rey Dela Cruz Santos which is
more particularly described as follows:

MAKE & TYPE : KIA PICANTO

MOTOR NO. : G4LAFP157491
CHASSIS NO. : KNABX512BGT235813
PLATE NO. : EG 6215 (Conduction Sticker/No)

2. That on November 12, 2017 at around 7:30 AM while driving said

vehicle, I accidentally bumped the steel no parking sign in Bulacan State
University compound;
 3. That as a result of which the right side door of said vehicle sustained
damage;

4. That likewise, while driving said vehicle along McArthur Highway,

Longos, Malolos City, Bulacan at around 5:30 PM on June 16, 2018, a
tricycle, accidentally bumped the left portion of my vehicle wherein the left
side door of said vehicle was damaged;

5. That I am executing this affidavit to attest to the veracity of the facts

contained herein and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 21 st day of

June, 2018 at Malolos City, Bulacan.

JOSELINE M. SANTOS
Affiant

SUBSCRIBED AND SWORN to before me this 21st day of June, 2018, at

Malolos City, Bulacan, affiant exhibiting to me her Driver License No. C07-
16016617, competent proof of identity, and known to me and to me known
personally to be the same person who executed the foregoing affidavit.

WITNESS MY HAND AND SEAL.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2018.

REPUBLIC OF THE PHILIPPINES )

MALOLOS CITY, BULACAN. . . . . ) S.S.
 AFFIDAVIT

I, MICHAEL C. VARGAS, of legal age, married, Filipino and resident of

Ph1 B7 L22 Avignon St., Camella Provence, Longos, Malolos City, Bulacan,
after having been duly sworn to in accordance with law, do hereby depose and
say:

1. That, I am the authorized driver of a certain motor vehicle, Ford

Ecosport with Conduction No. CO M156, registered under the name of my
spouse Sonia Marxyz Cruz Padilla-Vargas, more particularly described as
follows:

Make MODE COLOR PRODUCTION NO. ENGINE NO.

L
Ford Ecosport 1.5 Titanium 2017 Brisbane Brown MPBS0000SHA10682 UEJA5A10682
Powershipt

2. That on October 3, 2017 at around 8:00 o’clock in the evening, I

parked said vehicle infront of Rustica Restaurant located at The Cabanas,
Malolos City, Bulacan;

3. That when I came back, I found out that the said motor vehicle
sustained damages at its front right bumper;

4. That nobody noticed who and what caused the damage sustained by
the car since the same was left unattended;

5. That I am executing this affidavit to attest to the veracity of the facts

contained herein and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this 10 th day of

October 2017 at Malolos City, Bulacan.

MICHAEL C. VARGAS
Affiant

SUBSCRIBED AND SWORN to before me this 10 th day of October, 2017

at Malolos City, Bulacan, affiant exhibiting to me his Drivers License No.
C07-95124488, and known to me and to me known personally to be the same
person who executed the foregoing Affidavit.

REPUBLIC OF THE PHILIPPINES )

MALOLOS CITY, BULACAN. . . . . ) S.S.

AFFIDAVIT
I, MA. LAARNI DELA CRUZ BERNARDO, of legal age, married, Filipino
and resident of #14 B.E. Narra St., Sionson Subd., San Vicente, Malolos City,
Bulacan, after having been duly sworn to in accordance with law, do hereby
depose and say:
 1. That I am a duly license driver with Driver’s License No. C07-05-250628
which is valid until June 16, 2022;

2. That I am the wife of Kenneth Bryant B. Bernardo, the registered owner

of a motor vehicle, more particularly described as follows:

Make/Type MO CONDUCTIO CHASSIS NO. ENGINE NO.

DEL N NO.
Nissan Almera 2018 FOJ 203 BDUALBGN17C0 HR15948779D
0254

3. That last night, March 18, 2019, at around 7:00 o’clock in the evening,
while I was driving said vehicle and was to enter Brgy. Cofradia, Malolos
City, I accidentally hit a certain concrete fence which caused damage
both front and rear door of the right side of said vehicle;

4. That I am executing this affidavit to attest to the veracity of the facts

contained herein and for whatever legal intents and purposes it may
serve.

IN WITNESS WHEREOF, I have hereunto set my hands this 19 th day of

March, 2019 at Malolos City, Bulacan.

MA. LAARNI DELA CRUZ BERNARDO

Affiant

SUBSCRIBED AND SWORN to before me this 19 th day of March, 2019 at

Malolos City, Bulacan, affiant exhibiting to me his Driver’s License No. C07-
95-114705 and known to me and to me known personally to be the same
person who executed the foregoing Affidavit.

Doc. No. ___;

Page No. ___;
Book No.___;
Series of 2019.
REPUBLIC OF THE PHILIPPINES
PROVINCE OF BULACAN S.S.
MALOLOS CITY

AFFIDAVIT

I, WILSON VINCENT F. RAUSA, of legal age, Filipino, married, and a

resident of San Vicente, San Miguel, Bulacan, after having been duly sworn to
in accordance with law, do hereby deposes and states:

1. That I met an accident on November 24, 2018 at around 9:00pm while I

was driving a Toyota Wigo with Conduction Sticker No. A9A874, owned
by my wife LOUUIE MARRIE CARAG RAUSA;

2. That on said date and time, I was travelling along Brgy. Salangan, San
Miguel, Bulacan when a dog suddenly appeared and I accidentally
bumped it and rolled under the car;

3. That as a result of which the right front bumper, radiator grill and lower
portion of said vehicle sustained damage;

4. The damage is estimated to be in the amount of P32,323.00 evidenced by

an estimate from Toyota Motors Plaridel, Bulacan Branch.

5. That undersigned voluntarily executes this Affidavit for the purpose of

insurance claims 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 26 th of

November 2018, hereat Malolos City, Bulacan.

WILSON VINCENT F. RAUSA

Affiant

SUBSCRIBED AND SWORN to before me this 26 th day of November,

2018 at Malolos City, Bulacan, affiant exhibiting to me his Driver’s License
No. C07-03-242134, and known to me and to me known personally to be the
same person who executed the foregoing Affidavit.
Doc. No. ___;
Page No. ___;
Book No.___;
Series of 2018.

Moneuver
REPUBLIC OF THE PHILIPPINES
PROVINCE OF BULACAN S.S.
MALOLOS CITY

AFFIDAVIT

I, JOEL CARLOS HERNANDEZ, of legal age, single, Filipino and

resident of Guinhawa, Malolos City, Bulacan, after having been duly sworn to
in accordance with law, do hereby depose and say:

1. That, my sister, VILMA CARLOS HERNANDEZ is the registered owner

of a certain motor vehicle, Toyota HiAce GL Grandia with Plate No. ABD-1984
which is more particularly described as follows:

MAKE/TYPE MODE Plate No. CHASSIS ENGINE NO.

L
Toyota HiAce GL Grandia 2016 ABD-1984 JTFRS13P100044161 2KDA894418

2. That last night, September 15, 2019 at around 11:00 o’clock in the
evening, while I was driving said motor vehicle and due to heavy rain, I
accidentally hit the barrier/barbwire of the ongoing road construction along
Pinagbakahan, Malolos City;

3. That as a result of which, said motor vehicle sustained damages

(scratches) at its right side bumper, sliding door and other parts of the body;

4. That undersigned voluntarily executes this Affidavit for the purpose of

insurance claims and further, to attest the truth of all foregoing and for other
legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 16 th day of

September, 2019 at Malolos City, Bulacan.

JOEL CARLOS HERNANDEZ

Affiant

SUBSCRIBED AND SWORN to before me this 16 th day of September,

2019 at Malolos City, Bulacan, affiant exhibiting to me her Driver’s License ID
No. C07-98172187, a competent proof of identity, and known to me and to me
known personally to be the same person who executed the foregoing Affidavit.
.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2019.
 EXHIBIT E

1. That on said date and time, I was exiting to the right of our garage in San
Vicente, Apalit, Pampanga amidst rainfall and tinted windows were
closed when the side of the vehicle hit the concrete post of the garage;
REPUBLIKA NG PILIPINAS )
MALOLOS, BULACAN ) S.S.

SINUMPAANG SALAYSAY

Ako, si RIZALDY B. FAJARDO, may sapat na gulang, may-asawa, Pilipino at

naninirahan sa Kings Philips Royale Estates, Bulihan, Malolos City, Bulacan, matapos
makapanumpa nang naaayon sa batas ay malaya at kusang loob na dito ay
nagpapahayag:

1. Na ako ay pinahintulang magmaneho/magdala ng isang sasakyan, na pag-aari ng

aking balae na si Marietta L. Mijares na naninirahan sa Riverside Dolores, Capas,
Tarlac, makikilala sa mga sumusunod na palatandaan:

MAKE/TYPE MODE Plate No. CHASSIS ENGINE NO.

L
Toyota Fortuner 2017 CAC-4889 MHFJB8GS6H152269 2GDC150202
4

2. Na noong ika-20 ng Setyembre, 2019 sa Brgy. Ugong, Ortigas, Pasig, mga 5:15 ng
hapon habang ang nasabing sasakyan ay nakahimpil sa kadahilanang
naghihintay kami na mag “GREEN” ang traffic light nang biglang may
bumanggang tractor trailer sa likuran ng minamaneho kong sasakyan at ang
sasakyan na dala ko ay bumangga naman sa likuran ng motorsiklo na nakapwesto
sa aking harapan ;

3. Na nang may ilang saglit, napag-alaman ko na kaya nabangga ng tractor trailer

ang Fortuner na dala ko sa kadahilanang binangga di-umano ng isang wing van
truck ang nasabing tractor trailer, kaya nangkaroon ng karambola ang nasabing
mga sasakyan;

4. Na dahil dito, ang Fortuner na dala ko ang nagkaroon ng mga pinsala sa likuran,
gilid at harapan nito;

5. Na ginawa ko ang salaysay na ito upang patotohanan ang lahat na dito nasasaad.

SA KATOTOHANAN NG LAHAT, ako ay lumagda sa ibaba nito ngayong ika-25

ng Setyembrre, 2019, dito sa Malolos, Bulacan.

RIZALDY B. FAJARDO
Nagsalaysay
Drivers License No. N02-84-045229

SINUMPAAN AT NILAGDAAN sa harap ko ngayong ika-25 ng Setyembre 2019

dito sa Malolos, Bulacan.

Kas. Blg. __;

Pah. Blg. __;
Aklat Blg.__;
Taong 2019.
REPUBLIC OF THE PHILIPPINES )
MALOLOS CITY, BULACAN. . . . . . ) S.S.

AFFIDAVIT OF ACCIDENT

I, JUANITO N. DIENDO, of legal age, Filipino and resident of 230 F.D. Yabut
St., 7th Ave., Grace Park, Caloocan City, after having been duly sworn to in accordance
with law, do hereby depose and say:

1. That I am the authorized driver of a motor vehicle, Ford Ranger with Plate No.
CZM 925 registered under the name of Florencio D. Vargas, more particularly
described as follows:

MAKE/TYPE MODE Plate No. CHASSIS ENGINE NO.

L
Ford Ranger 2.OL Wild Track 2020 CZM 925 MNCUMFF40KWO2 YM2QWO29831
9831

2. That on December 5, 2019 at around 7:00 A.M., while I was driving, I was
following a dump truck within Km. 32 South Bound of the North Luzon Expressway and
with the territorial jurisdiction of Balintawak, a stone suddenly and accidentally hit my
windshield;

3. That as a result of which, my windshield was damaged;

4. That I am executing this affidavit to attest to the veracity of the facts contained
herein and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 10 th day of

December, 2019 at Malolos City, Bulacan.

JUANITO N. DIENDO
Affiant

SUBSCRIBED AND SWORN to before me this 10 th day of December, 2019 at

Malolos City, Bulacan, affiant exhibited to me his Driver’s License No. G01-92-147520, a
competent proof of identity, and known to me and to me known personally to be the
same person who executed the foregoing Affidavit.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2019.

REPUBLIC OF THE PHILIPPINES )

MALOLOS CITY, BULACAN. . . . . . ) S.S.

AFFIDAVIT OF ACCIDENT

I, JOEL REMOLIN CATEQUISTA, of legal age, Filipino and resident of 723

Purok Ibaba, Pinagbarilan, Baliuag, Bulacan, after having been duly sworn to in
accordance with law, do hereby depose and say:

1. That I am the registered owner of a motor vehicle, Honda Mobilio with

Conduction No. DS0991, more particularly described as follows:

MAKE/TYPE MODE Plate No. CHASSIS ENGINE NO.

L
Honda Mobilio 2015 DS0991 MRHDD4880FP0212 L15Z12103672
33

2. That on December 7, 2019 at around 11:20 A.M., while I was driving said
vehicle, I accidentally pumped the parking stopper of St. Augustine Square located at
Baliuag, Bulacan;

3. That as a result of which, front bumper of said vehicle was damaged;

4. That I am executing this affidavit to attest to the veracity of the facts contained
herein and for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 16 th day of

December, 2019 at Malolos City, Bulacan.

JOEL REMOLIN CATEQUISTA

Affiant

SUBSCRIBED AND SWORN to before me this 16 th day of December, 2019 at

Malolos City, Bulacan, affiant exhibited to me his Driver’s License No. C07-09-006399,
a competent proof of identity, and known to me and to me known personally to be the
same person who executed the foregoing Affidavit.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2019.
REPUBLIC OF THE PHILIPPINES
PROVINCE OF BULACAN S.S.
MALOLOS CITY

AFFIDAVIT

I, LEONARDO F. ZULUETA, of legal age, married, Filipino, and a

resident of Block 9 Lot 2 Regatta North Subd., Sumapang Matanda, Malolos
City, Bulacan. after having been duly sworn to in accordance with law, do
hereby deposes and states:

1. That on December 15, 2019, I met an accident at around 7:00PM while I

was driving my Toyota Hatchback, more particularly described as
follows:

MAKE/TYPE MODEL ENGINE CHASSIS NO. MV FILE

NO.
Toyota Hatchback 2016 2NZ7912997 MR2KW9F306 1301-662323
1123365

2. That on said date and time, while maneuvering said vehicle, in our
garage at Sumapang Matanda, Malolos City, Bulacan, I accidentally hit
our steel gate;

3. That as a consequence of which, the rear bumper (left side) of said

vehicle sustained damage;

4. That undersigned voluntarily executes this Affidavit for the purpose of

insurance claims 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 6 th day

of January, 2020, hereat Malolos City, Bulacan.

LEONARDO F. ZULUETA
Affiant
 SUBSCRIBED AND SWORN to before me this 6th day of January, 2020,
at Malolos City, Bulacan, affiant exhibiting to me his Drivers License No.
_______________, and known to me and to me known personally to be the same
person who executed the foregoing Affidavit.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2020.

REPUBLIC OF THE PHILIPPINES )

MALOLOS CITY, BULACAN. . . . . . ) S.S.

AFFIDAVIT OF ACCIDENT

I, ZENAIDA S. ROXAS, of legal age, Filipino and resident of Sergio Bayan,

Calumpit, Bulacan, after having been duly sworn to in accordance with law, do hereby
depose and say:

1. That I am the authorized driver of a motor vehicle, Toyota Wigo with Conduction
Sticker No. P6R321 registered under the name of my brother Jonathan Santos,
more particularly described as follows:

MAKE/TYPE MODE Conduction CHASSIS ENGINE NO.

L No.
TOYOTA WIGO 2020 P6R321 MHKA4DF5FLJ0398 1KRA536727
43

2. That on March 14, 2020, I met an accident at around 7:00PM while I was
driving said vehicle;

3. That on said date and time, while maneuvering said vehicle at

Malolos Sports Complex, Sta. Isabel, Malolos City, Bulacan, I
accidentally hit a plant box;

4. That as a result of which the right rear bumper (left side) and lower
portion of said vehicle sustained damage;

5. That undersigned voluntarily executes this Affidavit for the purpose of

insurance claims 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 16 th day

of March 2020, hereat Malolos City, Bulacan.

ZENAIDA S. ROXAS
Affiant
 SUBSCRIBED AND SWORN to before me this 16 th day of March, 2020,
at Malolos City, Bulacan, affiant exhibiting to me her Drivers License No. C07-
04-003208, and known to me and to me known personally to be the same
person who executed the foregoing Affidavit.

Doc. No. ___;

Page No. ___;
Book No.___;
Series of 2020.