Republic of the Philippines)

Pasig City )

SWORN AFFIDAVIT

I, PERPETUA CARPENA TAYAWA, of legal age, Filipino, and with address at

Cupang, City of Muntinlupa, after having sworn to in accordance with law, hereby depose and
state that:

1. I am the registered owner of a Mitsubishi Strada GLS SPT Pick-up with plate number
___________ and chassis no. MMBJYKL30FH002692 (“Pick-up” for brevity).

2. On 09 July 2017, at or about 8:00 o’clock in the morning, I was told that the vehicle
parked in front of me is going out, thus, I drove my pick-up out of the parking area near
my house so that the other vehicle can go out.

3. As I was about to re-park my vehicle, I accidentally made a hard push on the gas pedal
which caused my pick-up to suddenly accelerate. Due to the sudden acceleration, my
pick-up bumped into a post which caused damage to its front bumper, grill and other near
parts.

4. I execute this Affidavit to attest to the truthfulness of all my statements herein and for
whatever legal purposes it may serve.

Affiant sayeth naught.

PERPETUA CARPENA TAYAWA

Affiant

Acknowledgment

REPUBLIC OF THE PHILIPPINES )

Pasig City )S.S

Subscribed and sworn to before me this _______________________ affiant exhibited to

me as competent proof of identity her _________ with no. ______________ issued on
__________ at ________ City.

Doc. No. _______;

Page No. _______;
Book No. _______;
Series of 2017.

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