Republic of the Philippines )

CITY OF TANDAG ) S.S. 

Province of Surigao del Sur                    
                             

DRIVER’S AFFIDAVIT

 
I, NESTOR P. LUAD, of legal age, Filipino citizen, married and a resident of
Quirino (Poblacion), Madrid, Surigao del Sur, after having been sworn
in accordance with law hereby depose and state, THAT;
 
1. I am a duly licensed driver with Driver's License No. N03-94-174051;
2. I am the registered owner of one (1) unit Motor Vehicle, which is
more particularly described as follows:

Make/Body: NISSAN/PICK UP
Engine No. YD25851005T
Chassis No. _____________
Plate No.: LAF4436
Series No.: NAVARRA
Denomination: UTILITY VEHICLE

3. On June 22, 2023, around 7:00 in the evening, while the Nissan Pick Up
park in the garage of my residence at Quirino, Madrid, Surigao del Sur, I
noticed that the back windshield was already broke. I believed someone
might have broken the same while the vehicle was park. Please refer to
herewith attached pictures of damaged car;

4. I am executing this Affidavit to attest to the truth of the foregoing and in

support of my claim against the insurer for the repairs of the damage
caused to my vehicle and for whatever legal purposes this may serve
best.

IN WITNESS WHEREOF, I have hereunto set my hand this___________in

Tandag City, Surigao del Sur. Philippines

NESTOR P. LUAD
Affiant
Driver's License No. N03-94-174051

SUBSCRIBED AND SWORN to before me this ___________________ in

Tandag City, Surigao del Sur, Philippines and affiant exhibiting to me her valid
proof of identification. I hereby certify that I have examined the affiant and I am
convinced that he understood the same and confirmed its veracity.

Doc. No. _________

Page No. _________
Book No. _________
Series of 2023