REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ALBAY ) S.S.

TABACO CITY )
x------------------------------------------x

AFFIDAVIT

I, _____________________________ of legal age, Filipino citizen, ___________ and presently

residing at _________________ ___________________, after having been duly sworn to in
accordance with law, do hereby depose and say:

1. That I am the widow of BENITO D. DELA CRUZ who died on July 30, 2013 in Quezon City
because of head injuries sustained in a vehicular accident as per autopsy result conducted by
Dr. Lito R. Santos;

2. That per investigation of the Quezon City Police Station, my husband was driving along the
northbound lane of EDSA in front of Camp Aguinaldo in Quezon City when he was hit/bumped
by a truck coming from the opposite direction; copy of the Traffic Investigation Report is
hereto attached as Annex "A";

3. That at the time of the incident, my husband was a duly licensed driver carrying Driver's
License No. 123456 and was riding on a Toyota Innova, gray in color and with Plate No. XYZ-
123 owned by me with Certificate of Registration No. 55667788;

4. That I am executing this affidavit in support of my application for insurance claim with
_____________, to attest to the truth of the foregoing, and for whatever legal purposes it may
serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 6th day of October 2013 at Makati
City, Philippines.

_______________________________

Affiant

SUBSCRIBED AND SWORN to before me, this ____ day of __________ 20____, in the City of
__________________, by ___________________ with Passport No.________________ issued
on __________________ at _____________.

ATTY. ANTHONY CLARK A. GAPIDO

Notary Public Tabaco City
For the Province of Albay
Roll No. 83746
IBP OR No. 227570; June 13, 2022
PTR No. 8843533; July 13, 2022 at Tabaco City
MCLE: N/A (Newly Admitted to the Bar)
2nd Floor Coastal Building Rental, Purok 2,
Morales Street, San Roque,Tabaco City, 4511

Doc No.____;
Page No. 450;
Book No. 35 ;
Series of 2022