REPUBLIC OF THE PHILIPPINES)

CITY OF DAVAO . . . . . . . . . . .)S.S.

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AFFIDAVIT OF CLAIM
I, MARLENE D. QUINIQUITO of legal age, Filipino, and a resident of 22F Salvador
St., Sta. Lucia, San Juan, Metro Manila, Philippines, after having been duly sworn to in
accordance with law, do hereby depose and state:
That I am the registered owner of a certain one unit motor vehicle, particularly described
as follows:
Make

KAWASAKI

Chassis No.

AX125A-B04451

Series

AX125A

Model

2008

Plate No.

6101PC

C.R. No.

6597184-6

O.R. No.

4432183-0

That the aforementioned motor vehicle was borrowed by my friend JUVIE ESLABRA
ELUMBA, and it was brought to Brgy. Lumangin Igbaras, IloIlo City,
That sometimes on April 17, 2009 at Gines St., Brgy. 4 Poblacion of Igbaras Iloilo, the
dump truck bearing Plate No. GFH-633 owned by John Olivares, accidentally bumped the said
motor vehicle driven by JUVIE ELUMBA together with him, tandem at the back of motorcycle
his mother TRINIDAD ELUMBA Y ESLABRA, as a result of accident, the driver of motorcycle
was thrown away to the center of the road, the victims sustained multiple head and body injuries
and the driver Juvie Elumba and his mother was rushed by ambulance to Guimbal District
Hospital for immediate treatment because of seriousness of injuries sustained but pronounced
DEAD ON ARRIVAL by the attending physician;
That the said motorcycle incurred un estimated damages on its front fork shock,
headlight, left and right signal lights, rim, etc.;
That I am waiving my rights to claim whatever benefits that could extend to my damaged
motorcycle.
That I am executing this affidavit to attest to the truth of the foregoing statements, and for
whatever legal purpose it may serve.
IN WITNESS WHEREOF, I have hereunto set my signature this _____ day of
________________, at _______________, Philippines.

MARLENE D. QUINIQUITO
Affiant
SUBSCRIBED AND SWORN to before me this ________ day of _______________
2009 at ________________, Philippines.