REPUBLIC OF THE PHILIPPINES )

CITY OF SAN FERNANDO )SS.

PROVINCE OF PAMPANGA )

AFFIDAVIT

I, MARCOS D. SANTOS, of legal age, married, Filipino and a resident of Bagumbayan Pilar,
Bataan after having been duly sworn in accordance with law, depose and state that –

1. I am the driver with License No. C02-89-027543 of the following described motor
vehicle which was owned and registered under the name of Provincial Government of Bataan of
Provincial Capitol Compound, Balanga City, Bataan as per Certificate of Registration No.
____________ issued by the Land Transportation Office, to wit:

Make & Type……………………….. Toyota, HiAce GL Grandi

Model . ………..…………………… Van 2016
Plate No…………………………….. VE 170

2. On October 21, 2017 at around 03:30 o’clock in the afternoon, while driving the said
vehicle along Brgy., Ibayo, Balanga City, Bataan near Bataan Terminal when suddenly a Yamaha
Vega Force motorcycle with side car with Plate No. 4521RZ driven by Yasso Emmanuel B. Rivero
hit our motor vehicle caused the damaged to broke the bumper, left side mirror and several scratches
at the body was made;

3. That I have executed this affidavit to prove and establish the foregoing facts, to attest
to their truth and to enable to claim from the insurance and for all legal intents and purposes that it
may serve.

Affiant Further Sayeth None.

In Witness Whereof, I have hereunto affixed my signature this 25th day of October,
2017 at Balanga City, Bataan.

MARCOS D. SANTOS
Affiant
ID No. 13000179

SUBSCRIBED & SWORN before me this 25th day of October, 2017 at at Balanga
City, Bataan.