Republic of the Philippines) S.S.

City of Zamboanga )
x------------x
AFFIDAVIT

I, Nico C. Lauron ,Filipino, of legal age, single and a resident of Lantawan Drive,
Pasonanca Zamboanga City, Philippines, after being sworn to in accordance with
law, depose and state:
1. That I am a duly licensed driver with Driver's License No.J04-09-006346
covered by DLR No.192564761, which is valid until 2018-02-02.
2. That on 02 September 2017, at around 5:00 o’clock in the afternoon, I was
driving a motor vehicle owned and registered in the name of my mother
JOJI C. LAURON which is more particularly described as follows:
Make: ISUZU MU-X Conduction No. CN 7934
Serial no.: MPAUCR86GFT007842 Body Type: SUV
Engine No.: 4JK1NH9760 Year Model: 2015
Plate No.: NO PLATE AVAILABLE
3. That while I was slowly going out of our garage, the aforementioned
vehicle suddenly hit the post of the gate of our residence and as a result
the said vehicle sustained damage at its left side;
4. That I am executing this Affidavit to attest to the truth of the forgoing; in
support of the claim against the insurer for the repair of the damage
caused to my vehicle; and for whatever legal purpose this may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this 11th September
2017 in Zamboanga City, Philippines.

NICO C. LAURON
AFFIANT
SUBSCRIBED AND SWORN to before me this 11th day of September 2017 at
Zamboanga City, Philippines. Affiant exhibited to me as his valid proof of identity,
Driver’s License bearing No. J04-09-006346, issued at Zamboanga City, and
valid until February 02, 2018.

Doc. No. 01; JOHN JASON N. ALBRECHT

NOTARY PUBLIC
Page No. 02; RD
3 Level, Edificio Coastal
Book No. 01; Corcuera Street, Zamboanga City
P.T.R No. 1517990, 19 June 2017, Z.C
Series of 2017; Roll of Attorney’s No. 67102
I.B.P O.R No. 006219, 20 May 2017
Notarial Commission No. 56-2017