REPUBLIC OF THE PHILIPPINES

Province of Negros Occidental) S.S.

City of Bacolod)
AFFIDAVIT

I, IKEE G. RIZADA, of legal age, married, Filipino, with residence Purok Marapara,
Brgy. Bata, Bacolod City, Negros Occidental, after having been duly sworn to in accordance
with law, do hereby depose and state the following:

1. That I was the driver of the Nissan Urvan bearing Conduction Sticker Number OY
7379, owned by MARY JEAN B. UY, which was figured in an accident on May 20
2018 at around 7:45 PM along the intersection of Crossing Antipolo, Hda. Malinung,
Brgy. San Juan, Pontevedra, Negros Occidental (a copy of the Excerpt of Police
Blotter Entry No. 2018-05-965 is herein attached);
2. That the accident was occasioned by the fact that at the above-mentioned
intersection, I saw from a distance that the Motorcycle driven by a certain
DOMINADOR T. DIMAUSAY, came to a complete stop which prompted me to
continue driving towards the intersection;
3. That the driver of the said tricycle all of a sudden, without any warning or signal,
revved the vehicle towards the center of the intersection;
4. That despite attempts to maneuver the vehicle to avoid collision but the same
proved to be futile as our vehicles collided;
5. That the accident caused the instantaneous death of a certain GEORGE HAMIAS,
a back rider of the said tricycle, which was pronounced Dead on Arrival (DOA) by
the Valladolid District Hospital;
6. That the collision also caused injuries the amputation of the left leg of the driver;
7. That the other back rider NOLI M. ENCILA, only suffered minor injuries;
8. That the Nissan Urvan that I was driving also suffered damages to the following
parts of the vehicle:
i. Bumper
ii. Left Hand Side Head Lamps/Lights
iii. Left Hand Side Signal Lights
iv. Front Grille
v. Hood
9. That damage was caused purely by accident and without wanton diligence on my
part;
10. That I am executing this affidavit to attest to the truth of the foregoing statement
and in support of my claims for reimbursement from the insurance company.
IN WITNE ZZXASS WHEREOF, I have hereunto set my hands this _____ day of
_____________, 2018, in the City of Bacolod, Philippines.

IKEE G. RIZADA
AFFIANT
SUBSCRIBED AND SWORN to before me, this _____ day of ______________, 2018,
by IKEE G. RIZADA, who exhibited to me his Driver’s License 9(F01-11-000862) issued at
Bacolod City, Philippines.

Doc No. _______

Page No. _______
Book No. _______
Series of 2018