REPUBLIC OF THE PHILIPPINES )

PROVINCE OF BUKIDNON ) S.S.

MUNICIPALITY OF MARAMAG )

DRIVER’S AFFIDAVIT
I, LYSTER JUN MOMO CABALLES, of legal age, Filipino, married, and presently residing at
Purok 1, Kiburiao, Quezon, Bukidnon, after having been duly sworn to in accordance with law do
hereby depose and say;

A. That I am a holder of a Professional Driver’s license with No. K03-02-054359 which will expire
on May 11, 2032;

1. That I was driving my TOYOTA VIOS 1.3 XE CVT DJ-009 SEDAN with Plate No.
KAC8053, Engine No. 1NRX450242, Chassis No. PA1B13F38K4087509 with OR No.
1012-000000105399;

2. That on April 17, 2024, on or about 5:00 a.m. more or less at National Highway, Kiburiao,
Quezon, Bukidnon, while driving the above-mentioned vehicle from Kiburiao, Bukidnon
going to Purok 1, Kiburiao, Quezon, Bukidnon, a Dump Truck on the opposite direction was
running too fast;

3. As a result, flying stones hit my vehicle’s windshield, hood panel, rooftop, front door RH,
rear door RH, and rear fender RH of the said vehicle, hence the said body parts of the
vehicle incurred visible damages;

4. I am executing this affidavit to attest the truth of the foregoing statement, in support of my
insurance claim and whatever legal purpose it may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this 30th day of April 2024 at Maramag,
Bukidnon, Philippines.

LYSTER JUN MOMO CABALLES

Affiant
DL ID NO. K03-02-054359
Valid Until: 5/11/2032

SUBSCRIBED AND SWORN to before me, this 30 th day of April 2024 at Maramag, Bukidnon,
Philippines.

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