REPUBLIC OF THE PHILIPPINES)

MUNICIPALITY OF GUAGUA)
Province of Pampanga ) S.S.
x-------------------------------------x

AFFIDAVIT OF DRIVER
I, XXXXXXXXXXXXXXXXXX of legal age, Filipino, widower and a resident
of 442 Bancal, Guagua, Pampanga, after having been duly sworn to in
accordance with law, depose and state THAT:

1. That I am a duly licensed driver with Driver's License No.

XXXXXXXXXXXXX, which is valid until September 6, 2022.

2. That on November 9, 2019, at around 10:21pm, I was driving a motor

vehicle owned and registered in the name of by XXXXXXXXXXX which is
more particularly described as follows:

a. Make: Honda Motorcycle with Side Car

b. Plate No: XXXXXXXxx
c. Engine Number: XXXXXXXXXXXx
d. Chassis Number: XXXXXXXXXXXXx
e. Year: 2002

3. I was driving in San Matias, Guagua, Pampanga, near Petron Gas Station.
I was going in the direction towards the Diosdado P. Macapagal
Memorial Hospital. I suddenly felt dizzy and lost consciousness. I did
not know that I collided with the metal fence/barrier in the middle of
the road.

4. As proof, I have attached a copy of the traffic accident report issued by

the Guagua PNP. It is marked as Annex A.

5. That I am executing this Affidavit to attest to the truth of the forgoing

and in support of the claim against the insurer for the repair of the
damage caused to my vehicle

IN WITNESS WHEREOF, I have hereunto set my hand this November 27,

2019 in Guagua, Pampanga, Philippines.

XXXXXXXXXXXXXXXXXXXXx
Affiant

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 SUBSCRIBED AND SWORN to before me this November 27, 2019 in
Guagua, Pampanga. Affiants exhibited to me his Driver’s License with
no.XXXXXXXXXXXXXXXXXXX bearing their picture and signature.

WITNESS MY HAND AND SEAL OF OUR OFFICE.

CONTROL No.
XXXXXXXXXXXXXXXXXx
XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXX
(Pursuant to R.A. No. 9406)

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