ASSUMPTION OF LIABILITY

I/We, MC DONAN VILLARINO MILAN, Filipino, of legal age, single/married, with

principal address at Blk2 Lot 55 Seamen’s Village Brgy. Sampaloc 3, Piela, Dasmarinas, Cavite
after having been duly sworn to in accordance with law hereby depose and say:

That I/We are the owner of a motor vehicle more particularly described as follows:

MAKE / TYPE : TOYOTA AVANZA E 1.3 A/T

YEAR MODEL : 2018
MOTOR NO. : 1NRF401218
CHASSIS NO. : MHKM5EF2FJK014902
PLATE NO. : NAO7873

That said motor vehicle is insured with Standard Insurance Co., Inc. under Policy No.
GC-PCV-100847254, with the following coverage:

OWN DAMAGE : 495,000.00

THEFT : 495,000.00
CTPL : -na-
EXCESS BODILY INJURY : 200,000.00
THIRD PARTY PROPERTY DAMAGE : 200,000.00

That said motor vehicle was involved in an accident on June 25, 2023 at the Parking lot
of Pagcor Tagaytay at Brgy Kaybagal South which gave rise to a Third Party Claim (Third
Party Property Damage) of CARIDAD M. HERNANDEZ driven by JEMIAS y
EVANGELISTA HERNANDEZ / 2016 TOYOTA FORTUNER 4x2 bearing plate number
NDX7967 ;

That Standard Insurance Co., Inc. has issued a check payable in my name in the amount
of Two Hundred Thousand Pesos and 00/100 only (P200,000.00), covering the full and final
settlement of the aforestated claim.

That I assume any other responsibility for payment of the damage, loss or injury
sustained by the Third Party herein in connection with the said accident of June 25, 2023, and
hereby release and discharge Standard Insurance Co., Inc. and hold free and harmless all of its
stakeholders, directors, officers, and employees from any and all claims, actions, suits and
liabilities, whatsoever, arising therefrom.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _____ day of

__________________ in the City of ________________.

MC DONAN VILLARINO MILAN

Affiant

WITNESSES:

_____________________________________ _____________________________________

REPUBLIC OF THE PHILIPPINES

_____________________________ ) S.S.
x------------------------------------------x

SUBSCRIBED AND SWORN to before me this ______________. Affiant exhibiting to

me his/her __________________________________ (competent evidence of identity) issued on
________________ and valid until_______________.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of ______.