Republic of the Philippines )

Cainta, Rizal ) SS.

AFFIDAVIT
I, ANGELITO TERO ANDAYA, Filipino, of legal age, and a resident of No.
Alley 1 Block 2, Lot 20 Greensite Compound, Barangay Santa Lucia, Pasig City under
oath, do hereby depose and state, that:

I am the registered owner of a motor vehicle which is herein below more

particularly described as follows:

Make/Series/Type : Suzuki/ FU150SCD2/ Motorcycle

Year Model : 2015
MV File No. : 0701-00000148669
Engine No. : G427224259
Chassis No. : BG41H302347
CR No. : 217486603/ 05/19/2015
LTO Region 7

On October 13, 2020, at around 8 a.m., I was traversing Ortigas Avenue

Extension, east bound with the aforesaid vehicle. At the intersection near Petron Gas
Station, in front of Park Place Executive Village, Cainta, Rizal, a tricycle suddenly
emerged, trying to manage a “u-turn” from the incoming traffic, instantly hitting and
throwing me off to the pavement. I was then rushed to the Hospital in Quezon City for
immediate treatment;

I am executing this AFFIDAVIT to attest to the veracity of the foregoing

statements as part of the requirements for my insurance claims and Social Security
System Benefits and for purposes not contrary to law, morals, good customs and public
policy;

IN WITNESS WHEREOF, I have hereunto set my hand this 19th day of October
2020 at Cainta, Rizal.

ANGELITO TERO ANDAYA

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME on the date and at the place

above-written. Affiant exhibited to me his Driver’s License bearing License No. A02-85-
005027 issued by Land Transportation Office, and valid until 2022/09/23 as competent
proof of identification.

Atty. CRISPINO T. PABLO, JR.

Doc. No. 479 ; NOTARY PUBLIC
Appointment No. 20-21
Page No. 96 ; Valid until December 31, 2021
PTR No. 13694609A/Jan. 2, 2020/Rizal
Book No. LXXXIV ; IBP Life Time No.06272/Rizal
Roll No. 49638
Series of 2020. MCLE Compliance No. V-0022925