Republic of the Philippines )

Province of Pangasinan ) s.s.

Municipality of Lingayen )

AFFIDAVIT

I, ESMERALDO SANCHEZ CACATIAN, of legal age, married, Filipino citizen,

and resident of Basing East, Lingayen, Pangasinan, after having been duly sworn to in
accordance with law, hereby depose and say:

1. That I am the authorized driver and the registered owner of a Toyota Fortuner with plate
number IAA 9889, and more specifically described as follows:

MV File No. 0101-00000444229

Engine No. 2GDC234664
Chassis No. MHFJB8GS6H1537146
Year No. 2018

2. That on the evening of October 28, 2022, I was driving along Basing Tumbar,
Lingayen, Pangasinan. Due to the heavy rain brought about by the severe weather
condition on that day, I accidentally drove the said vehicle to a dike;

3. That said incident was a result of a miscalculation in driving, and as a consequence,

the front bumper of the said vehicle, including its grill, Fenders, Right Hand Cladding
Clips, Right hand Retainer, Rear Bumper, Left Hand Foglamp, Bumper Step Guard
Rear, Hood, front Head Lights, Side Mirror both left and right, Front Fenders and
Mudguards, Sensors, Clutch Disc and cover, Clutch Release Bearing, Fork, and Fork
Support, Bearing and Fork Boot, incurred damages of undetermined value;

4. That I am executing this affidavit to attest to the truth of all the foregoing and as a
basis for my insurance claim.

Lingayen, Pangasinan, this 9th day of November, 2022.

ESMERALDO SANCHEZ CACATIAN

Affiant
Driver’s License No. A07-03-048871
To expire on 2022/12/25

SUBSCRIBED AND SWORN to before me this 9th day of November 2022 at

Lingayen, Pangasinan, affiant exhibiting to me his government issued ID written below his
name as proof of his identity.

Doc. No. ___ ;

Page No. ___ ;
Book No. ___ ;
Series of 2022.