REPUBLIC OF THE PHLIPPINES.

)
ILOILO CITY ) S. S.

AFFIDAVIT

I, ELESAR S. SEGUMALIAN, of legal age, Filipino, single., and a resident of Guzman

Jesena St. Mandurriao, Iloilo City, after having been duly sworn to in accordance with law,
hereby depose and state:

1. That I am a duly licensed driver with Driver’s License No. FO8-12-000800 which is
valid until May 16, 2022;
2. That on May 13, 2020 at around 10:30 in the morning, I was driving the vehicle
owned and registered under the name of MEGLYKA P. DIONELA, which is more
particular described as follows:
Make: Mitsubishi Motor No.:
Series:Strada Chasis No.:
Body Type: Pick-Up Plate No.: B5I119

Year Model: 2019

3. That I was on my way out of parking lot of my apartment located at Amysville,
Mandurriao, Iloilo City, when I accidentally slammed the accelerator pedal, in which
the vehicle suddenly hit the post situated in the front of our gate, as a result the left
back part of the vehicle sustained damage;
4. I am executing this Affidavit to attest the truth of the foregoing and in support of the
claim against the insurer of the damage caused to my vehicle.

Signed on 18th day of May 2020, Iloilo City.

ELESAR S. SEGUMALIAN
Affiant

SUBSCRIBED AND SWORN TO before me this 18th day of May 2020 at Iloilo City.
Affiant exhibited to me Driver’s License No. FO8-12-000800 as his competent evidence of his
identity.

Doc No.____
Page No. ____
Book No. ____
Series of 2020