Republic of the Philippines )

Cainta, Rizal ) SS.

AFFIDAVIT

I, HOMERLITO JR. M. CHUA, Filipino, of legal age, and a resident of No. 34

Robin Street, Don Mariano Subdivision, Barangay San Juan, Cainta, Rizal, under oath,
do hereby depose and state, that:

I am the driver of the motor vehicle registered under the name of Jaymart M.
Zapanta, and which is herein below more particularly described as follows:

Make/Series/Body : Toyota/Vios 1.3E Gas A/Sedan

Year Model : 2016
MV File No. : 1301-00000663804
Plate No. : NDV8934
Engine No. : 2NZ7919620
Chassis No. : PA1BW9F3XG2077975

On December 10, 2023, on or about 4:00 p.m., as I was maneuvering the above-
vehicle from the garage of our residence, I miscalculated the distance which caused me
to scraped/grazed on the gate post. Consequent thereto, the motor vehicle sustained
scratches on the rear-right fender and door panel;

The above-vehicle is insured at People’s General Insurance Corporation under

Policy No. ____________________;

This affidavit is being executed to attest to the veracity of the foregoing statement
in order to establish the aforesaid facts for purposes not contrary to law, morals, good
custom and public policy.

IN WITNESS WHEREOF I have hereunto set my hand this 6 th day of February

2024 at Cainta, Rizal.

______________________
HOMERLITO JR. M. CHUA
Affiant

SUBSCRIBED AND SWORN TO before me on the date and at the place above-
written, affiant exhibiting to me his Driver’s License No. D19-23-002536, valid until
October 20, 2027, bearing his photo and signature.

Doc. No. ;
Page No. ;
Book No. ;
Series of 2024.