(Affidavit in Support of Complaint for Reckless Imprudence resulting to

multiple physical injuries and Damage to Property)

Republic of the Philippines

Province of Quezon
Municipality of Calauag s.s.
x--------------------x

A F F I D A V I T - C O M P LA I N T

We, ________________, Filipino, of legal age, single and a resident of

______________, Philippines and _____________________, after being sworn in
accordance with law, depose and state to wit:

1. That, We, ______________________, bus driver and

___________, bus inspector duly assigned/representative of
______________are regular employees of ___________, a domestic
corporation duly organized in accordance with law and engaged in
transportation industry in the Philippines, having a postal address at No.
______________________________City. That, I am a duly licensed bus
driver with Professional Driver's License No.____________, which is
valid until the year ______and the bus driver of ________________,
which vehicle is specifically described as with Motor No.____________,
Chassis No. ___________and with plate No. ____________ issued by the
Land Transportation Office of the City of _____________and is
registered in the name of____________,with Certificate of Registration
No ____________issued on____________and with MVMRR No.
___________dated___________:

2. That on May 17, 2017 at around 4:50 AM, while I was

traversing along Maharlika Highway within the vicinity of Barangay
Doa Aurora , Municipality of Calauag, Province of Quezon bound to
Manila from Ormoc City and upon passing the curve and descending
portion of the national highway when a Toyota Avanza Blue bearing
plate No. __________, with vehicle sales invoice no. , registered to
_______________of Brgy. ________________and being driven by
______________, 42 yrs of age with Professional Drivers License no.
______________ and a resident of ________________________,;

3. That by reason of a negligent driving proficiency, without

exercising ordinary care and prudence and in due disregard of the safety
driving skills and procedures tantamount to violation of the traffic rules
and regulations duly implemented by law, the aforementioned driver of
the vehicle at fault, in a recklessly speeding motion, driving and coming
 from an opposite direction and without any warning whatsoever
suddenly swerved to my lane and hit the right front side of the bus I was
driving and as a consequence thereof a strong impact had created which
caused the bus to move instantaneously to the right side of the highway
and fell at the narrow valley with an approximate profundity measuring
10 to 15 feet from the National Highway;

4. As a result thereof, thirteen (13 passengers) of the said

passenger bus suffered physical injuries and the bus incurred an
estimated amount of damage up to 1.2 million pesos;

5. That the said actual and upshot of the collision incident was
witnessed by many persons, most of them were the victims, including
the Bus Inspectors of the bus I was driving in the person of Mr.
____________ and Mr. ___________ who immediately responded to the
sight upon receiving the incident report. That the said incident report
was duly documented and recorded in the Blotter Entry of Quezon
Police Station in Calauag, Quezon, specifically, to wit:

COLLISION INCIDENT:

ENTRY NUMBER:
DATE:
TIME: 5:10AM

The copy of the Blotter Certificate is here to reproduce as

Annex A and made integral part hereof.

Likewise, the names of passengers who suffered physical

injuries were listed in the same Police blotter Certificate and marked as
Annex B for purposes of reference (italics supplied);

6. That, we are executing this Affidavit to attest to the truth adn

veracity of the foregoing and in support of charges for "RECKLESS
IMPRUDENCE RESULTING TO MULTIPLE PHYSICAL INJURIES AND
DAMAGE TO PROPERTY" against the driver of the said Toyota Avanza
Blue specifically described above and/or for whatever other action that
may be filed against the driver and/or registered owner of the said
vehicle and in support of claims against the insurer/s for the
repair of the damage caused to the vehicle I was driving and to the
medical expenses incurred by the foregoing passenger victims as a result
of the above mentioned incident.
 IN WITNESS WHEREOF, We have hereunto set our hands
this____________in_____________, Philippines.

AFFIANT AFFIANT

Drivers license No: Drivers License No:

Subscribed and sworn to this ______________of ___________ the affiants

personally made known to me and who made the above mentioned Affidavit
complaint for reckless imprudence resulting to multiple physical injuries and
damage to property.