Republic of the Philippines )

Tacloban City ) S.S.

DRIVER’S AFFIDAVIT OF INCIDENCE

I, JOEDY A. LATO, Filipino, of legal age, and a resident of Brgy. 49, Youngfield,
Tacloban City, Leyte after having been duly sworn to in accordance with law hereby
depose and state that:

1. I am the owner of a Toyota Sports Utility Vehicle (SUV). The said motor vehicle is
registered under Certificate of Registration No: 344710321 and Official Receipt
No.: 1614530341.

Details of the motor vehicle more particularly described herein as follows, to wit:

Make: TOYOTA MV File No: 0801-00000232455

Series: Fortuner 2.4L 4 Body Type: SUV
Engine No.: 2GDC513976 Chassis No:
Plate No.: HAB 3041

2. On April 11, 2019, at around nighttime, I went to Southern Comfort Pension House
located in Maasin, Southern Leyte. I properly parked the said Ford pick-up truck
in front of an establishment called Personal Collection. Such establishment was
within the premises of the said pension house where I was to stay for the night;

3. On April 12, 2019, at around 7:00 o’clock in the morning, I went to check my motor
vehicle and saw that the pick-up sustained a very long, deep scratch on its left side
(driver’s side) starting from the head light down to the tail light. The same tail light
was also damaged;

4. I exercised all due diligence and efforts in trying to avoid the said incident but all
such efforts were for naught;

5. I am executing the foregoing affidavit in compliance with the requirements for

insurance claims for the above-described vehicle; and

6. I have executed this affidavit to attest to the truth and veracity of the foregoing
statements, and for whatever other legal purposes the same may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 19th day of June
2019, in the City of Tacloban, Leyte, Philippines.

JOEDY A. LATO
Affiant
License No.: H02-96-039706

SUBSCRIBED AND SWORN TO Before me a Notary Public for and in the City of
Tacloban, Leyte, Philippines, this 19th day of June 2019. Witness my hand and seal.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2019