Republic of the Philippines )

Province of Pangasinan ) s.s.

Municipality of Lingayen )

AFFIDAVIT

I, RICHARD OPIANA PEREZ, of legal age, Filipino citizen, and resident of

#217 Caloocan Norte, Binmaley, Pangasinan, after having been duly sworn to in
accordance with law, hereby depose and say:

1. That I am the authorized driver and owner of a Ford Ecosport with Plate Number
ABI-3352, and more specifically described as follows

MV File No. 0101-00000156640

Engine No. UEJAFE17063
Denomination: Sports Utility Vehicle
Year Model: 2015
C.R. No. 252764956

2. That sometime around the second week of November, 2022, my wife and I
went to the Magic Club Grocery Store of Binmaley Pangasinan and we parked our
car in the establishment’s parking area. As we finished our grocery shopping, we
came back to our car and saw a parked motorcycle beside our car fall and bump
against our car;

3. That as a result of the incident, the lower portion of the rear righthand
passenger side door of the said vehicle was dented and incurred scratches of
undetermined value;

4. That I am executing this affidavit to attest to the truth of all the foregoing, as
a basis for my insurance claim, and for all legal purpose it may serve.

FURTHER, AFFIANT SAYETH NAUGHT.

RICHARD OPIANA PEREZ

Affiant
Driver’s License No. A07-05-000838
To expire 2032/05/01.

SUBSCRIBED AND SWORN to before me this 18TH day of November 2022 at

Lingayen, Pangasinan.

Doc. No. ___ ;

Page No. ___ ;
Book No. ___ ;
Series of 2022.