Republic of the Philippines )

Cainta, Rizal ) SS.

AFFIDAVIT

I, JON KELVIN S. SIBAYAN, Filipino, of legal age, married and a resident of

Block 10, Lot 10 Carnation Street, Midtown Village, Barangay San Andres, Cainta,
Rizal, under oath, do hereby depose and state, that:

I am the driver of the motorcycle registered under the name of my wife, Angelica
Joice Sibayan, and which is herein below more particularly described as follows:

Make/Series/Body : Suzuki/Ciaz/Sedan
Year Model : 2019
Chassis No. : MMSVC41S9KR102698
Engine No. : K14BS152779
Plate No. : NEA4174
MV File No. : 1366-00000241916

On September 8, 2023, on or about 10:00 a.m., while I was traversing along

Barangay 133, Protacio, Pasay, my vehicle was accidentally grazed by a truck parked
on road-side. Due to the aforesaid accident, the vehicle sustained dent/scratches on the
full left part;

On December 23, 2023, on or about 5:00 p.m., while I was traversing along
Barangay 183, Villamor Airbase when I accidentally ran along the road gutter. Due to
the aforesaid accident, the vehicle sustained dent/scratches on the right portion of the
front bumper;

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 5th day of January
2024 at Cainta, Rizal.

JON KELVIN S. SIBAYAN

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. Driver’s License No. N01-14-
038783, valid until February 7, 2032, bearing his photo and signature.

Doc. No. 483 ;

Page No. 97 ;
Book No. II ;
Series of 2024.