REPUBLIC OF THE PHILIPPINES )

CITY OF CAGAYAN DE ORO ……) S.S.

DRIVER'S AFFIDAVIT

I, ULYSSES G. AGUILAR, of legal age, Filipino, married a resident of

Lumbia, Cagayan de Oro City after having been duly sworn to in accordance
with law do hereby depose and say:

1. That I am the owner and driver of Toyota Hilux pick-up with plate no.
KFK-131;

2. That last September 6, 2011 at around 9:00 O’clock in the morning at

the East Terminal, parking area, Gusa, Cagayan de Oro City while I
was about to move backward, unfortunately, I happened to bumped
the front bumper of the double tire Jeep vehicle;

3. That as a result no damaged on the part of the double tire vehicle but
on my side my driven vehicle was damaged in the left side of the rare
bumper and the tale gate of the said pick-up was dainted;

4. That the extend of the damaged as to money value of which could be

appraised by a license mechanic or an experienced vehicle body
builder.

IN WITNESS HEREOF, I have hereunto affixed my signature this

________ at Cagayan de Oro City, Philippines.

ULYSSES G. AGUILAR
Affiant

SUBSCRIBED AND SWORN to before me this __________ at Cagayan

de Oro City, Philippines.

Doc. No. ______;

Page No. ______; NOTARY PUBLIC
Book No. ______;
Series of 2011.