REPUBLIC OF THE PHILIPPINES )

CITY OF BATAC ) S.S.

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AFFIDAVIT

I, RICHARD TABISULA y Medrano, of legal age, married and a resident of

Brgy. 16-S Quiling Sur, Batac City, Ilocos Norte, after having been duly sworn to in
accordance with law do hereby depose and state that:

1. I am the husband of the registered owner of a motor vehicle which is more

particularly described as follows:

Make : Ford
Series : Everest Ambient
MV File No. : 0301-00000428164
Engine No. : P4AT2349622
Chassis No. : MNCAXXMAWAGS06533
Plate No. : CAE2364

2. On June 25, 2022, in the afternoon thereof and while I was driving the above-
mentioned motor vehicle in the municipality of San Nicolas, Ilocos Norte when
suddenly an empty truck overtook and suddenly a stone hit the windshield of the
car causing it to crack and was already damaged;
3. I have no knowledge of the facts indicating as to who was responsible for the said
damages;
4. I attest to the truthfulness of the above facts and I am executing this affidavit in
order to recover insurance proceeds and other purposes as it may best serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 30 th of June

2022 at the City of Batac, Ilocos Norte, Philippines.

RICHARD TABISULA
Affiant

SUBSCRIBED AND SWORN TO before me this 30th of June 2022 at Batac

City, Ilocos Norte, Philippines.