REPUBLIC OF THE PHILLIPPINES)
PROVINCE OF SAMAR…………...) S.S.
CITY OF CATBALOGAN………….)
AFFIDAVIT
I, GILBERT P. UY, of legal age, married, Filipino, and with residence at Brgy.
Matulungin, Jiabong, Samar, after having been duly sworn to in accordance with law,
do hereby depose and state: that-
1. I am the lawful registered owner and actual possessor of a
motor vehicle particularly described as follows:
MV File No. : 0801-00000023099
Plate No. : HAD2104
ENGINE NO. : P4AT2070405
CHASSIS NO. : MNGAXXMAWAFS70473;
MAKE /SERIES : FORD/EVEREST AMBIENT;
BODY TYPE : WAGON;
2. On 23 October 2024, at about 10:40 a.m., within the vicinity of
Brgy. 92, Tacloban City, I was driving the above-described vehicle and a
vehicle, a Mitsubishi Strada, which was ahead of me also traversing the
same lane heading towards Abucay from Apitong;
3. However, the said vehicle which was ahead of me suddenly
stopped, and as such, causes me to react belatedly, bumped to it resulting
both vehicles to some minor damages; the afore-described vehicle,
particularly sustained said dents and scratches on its front bumper and
hood; photographs depicting the vehicle damage are hereto attached; and
4. I am executing this statement to attest the truth of all the foregoing
and in support of the claim against the insurer for the repair of the damage
caused to said vehicle and for other legal purposes.
IN WITNESS WHEREOF, I have hereunto affixed my signature this 13 th day of
November 2024 at Catbalogan City.
GILBERT P. UY
Affiant
SUBSCRIBED AND SWORN to before me this 13 th day of October 2024 in
Catbalogan City, affiant exhibiting to me his Driver’s License ID No. H01-96-001146.
