Republic of the Philippines)

Province of Surigao del Sur)s.s.

Municipality of Tago . . . . .)
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AFFIDAVIT OF UNDERTAKING

I, LEONES GLORY DIONIO, of legal age, Filipino, married and a presently

residing at Gamut, Tago, Surigao del Sur, Philippines after having been duly sworn to in
accordance with law hereby depose and say:

1. That I am the trustee of a single motorcycle owned by Alfredo Espinosa,

particularly described below:

Make: HONDA
Model: XR 125
Color: Red/Black
Plate Number: 22575
Engine Number: JD21E2213816
Chassis Number: LTMJD210E5222005

3. That on October 11, 2016, at around 9:00 o’clock in the morning, said
motorcycle, driven by Joseph Lawrence Nye, had figured in an accident at
Magroyong, San Miguel, Surigao del Sur, which resulted to the injuries
suffered by Desideria Camingawan;

4. That as a consequence, the single motorcycle has been impounded at San

Miguel Police Station, San Miguel, Surigao del Sur;

5. That as the trustee of the said motorcycle, I earnestly request the Chief of
Police of San Miguel, Surigao del Sur, that it be released to me and I hereby
undertake to present the same to the Police Station/Court whenever it is
required or needed;

6. That I am executing this affidavit to attest to the truthfulness of the

foregoing facts and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 20 th day of October

2016 in Tago, Surigao del Sur, Philippines.

LEONES GLORY DIONIO

Affiant
TIN: 917-550-752-000

SUBSCRIBED AND SWORN TO before me this 20th day of October 2016 at

Tago, Surigao del Sur, Philippines.