Republic of the Philippines )

Bacolod, Lanao del Norte ) S.S.

AFFIDAVIT

I, RICKY C. SUCUANO, of legal age, married, Filipino and a resident of Purok

6, Poblacion, Bacolod, Lanao del Norte, after having been sworn in accordance with
law, depose and state:

1) That I am the Driver of Mitsubishi L300, owned by Bacolod Water District, the
said vehicle is identified as follows:

Brand: Mitsubishi
Model/Year/Color: 1998
Engine No.: 4D56A-EE4773
Serial/Chassis No.: L039PYZL-04816
Certificate of Registration No.: 1393083-6
Official Receipt No. : 1552829865
Plate No. : SHS-392

2) That on August 16, 2019 while driving the said vehicle, I met an accident with
one Yamaha Sniper 150 MXI driven by Brandon James T. Roldan at Poblacion, Bacolod,
Lanao del Norte;
3) As a result thereof, the vehicle that I am driving sustained damage to wit: the
bumper and the left side signal light;
4) That I am executing this affidavit to attest to the truth of the foregoing, for
making an insurance claim, and for whatever other legal purposes this affidavit may
serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 11th day of

September 2019 in Bacolod, Lanao del Norte.

RICKY C. SUCUANO
Affiant

SUBSCRIBED AND SWORN TO before me this 6th day of 11th day of September
2019 in Bacolod, Lanao del Norte, affiant personally appearing and known to me to be
the same person who executed the foregoing instrument, exhibiting his Driver’s License
M02-08-000317 issued in Iligan City.

WITNESS MY HAND AND SEAL.

ATTY. ALFONS JANSSEN P. MARCERA

Notary Public
Serial No. 19-229
Iligan City- Lanao del Norte
Until December 31, 2020
Doc. No. : 61; IBP Lifetime No. 01840
Page No. : 13; Roll No. 70427- July 31, 2017
Book No. : VIII; PTR No. 3838881- January 8,2019
Series of 2019. MCLE Compliance No VI- 0022669- 8-18-18