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Republic of the Philippines )

Province of Oriental Mindoro )S.S.


Municipality of Gloria )
x----------x

AFFIDAVIT OF UNDERTAKING

I, EVELYN BAYLON LACANLALE, married, Filipino, of legal age, and a resident of


Barangay Maragooc, Gloria, Oriental Mindoro, Philippines, after being duly sworn to in
accordance with law, hereby depose and state:

1. That I am the spouse of the registered owner Mr. AMANDO MALLARI LACANLALE
of a Motor Vehicle more particularly described as follows:
MAKE/SERIES: ENGINE NO:
KAWASAKI BARAKO
PLATE: DC90821 TYPE OF BODY: MC
FILE NO: CR NO:
YEAR MODEL:

2. That the said vehicle figured in a traffic incident in Brgy. G. Antonino, Gloria, Oriental
Mindoro, on November 12, 2016 at around 10:00 in the evening. That after the incident
the vehicle was impounded at Gloria Municipal Police Station.
3. That because of the accident, my Spouse suffered injuries to various part of his body
including a crack on his head. As a result he is currently mentally incapacitated and
suffering from loss of memory and conciousness.
4. That as of the moment, there is no pending Criminal, Civil or Administrative Case filed
against my spouse in any Trial Courts in Oriental Mindoro;
5. That, the said vehicle is necessary for me to continue my business in order to sustain the
medical requirements of my husband.
6. That the photos of the vehicle was already captured and recorded by the Police and if I
learn that the said vehicle is necessary to be presented, I shall report in person within five
(5) days from knowledge to the Gloria Municipal Police Station or respective courts, and
present the vehicle when required;
7. That I declare under the penalties of perjury, the above information are verified by me,
and to the best of my knowledge are true and correct or based on authentic documents.

IN WITNESS WHEREOF, I have hereunto set my hand this 12 th day of January 2017 at Gloria,
Oriental Mindoro, Philippines.
______________________________
EVELYN BAYLON LACANLALE
(Affiant)

SUBSCRIBED AND SWORN to before me this 11th day of January 2017 at Gloria, Oriental
Mindoro, affiants exhibiting to me her TIN NO. 453-530-530-000.