Republic of the Philippines )

San Carlos City, Pangasinan) s.s.

AFFIDAVIT

I, DICK A. CURAMING, of legal age, married, Filipino and a resident of #69 Sta. Isabel
Subd., Palaris St., San Carlos City, Pangasinan, after having been duly sworn to in accordance
with law do hereby depose and states:

1. That I am the driver of a Mercedes MB100 with Plate number ADV 217 and still
registered in the name of MARINA C. ARELLANO but owned and purchased by MARIO A.
CURAMING. Copy of the Certificate of Registration and Official Receipt are hereto
attached and forming part hereof as Annexes “A” and “B”;

2. Sometime on September 22, 2012, I was driving carefully my motor vehicle on my way
home when I accidentally hit and bumped a motorized tricycle with plate number 1057-
AM with a boarding two minors namely: Geanne Cataline R. Perez and Gere Federie R.
Perez and the driver named Gerry P. Perez and Tina R. Perez;

3. That the accident happened in Brgy. Talang, San Carlos City, Pangasinan;

4. That the passengers of motorized tricycle were immediately rushed to the Virgen
Milagrosa Medical Center, San Carlos City, Pangasinan for their immediate medical
attention;

5. That the incident was entered into blotter, evidenced by Certification of the PNP San
Carlos City,Pangasinan;

6. That I am executing this affidavit to attest to the truth of the foregoing statement and
for the purposes of claiming insurance from the insurer/insurance company.

IN WITNESS WHEREOF, I hereby affix my signature this 31 st day of October 2012 at San
Carlos City, Pangasinan.

DICK A. CURAMING
Affiant
Driver’s License No.A-12-01016963
Expires 2013-0-20

SUBSCRIBED AND SWORN to before me this 3 1st day of October 2012 at San Carlos City,
Pangasinan.

Doc No. ___

Page No. ___
Book No. ___
Series of 2012.