Republic of the Philippines)

Province of Laguna ) s.s.

City of Calamba )

AFFIDAVIT OF INCIDENT REPORT

I, JONALYN L. VILLALUZ, legal age, Filipino, married, and a resident of Blk. 49 Lot 28 Laguna
Buenavista, Calamba City, Laguna, after having been sworn to in accordance with law, do hereby
depose and say that:

1. I am a holder of a Non-Professional Driver’s License No. N26-19-011685, which is valid until

November 04, 2023.

2. On October 1, 2022 at 10:00 o’clock in the morning, I was driving a Mitsubishi Mirage G4
GLX1 vehicle registered to me, and more particularly described as follows:

Make: Mitsubishi Engine No.: 3A92UHG0721

Series: MIRAGE G4 GLX1 Chassis No.: PAEA13TJJJA007975
Body Type: SEDAN Plate No.: DAK3693
Year Model: 2018 MV File No.: 0401-00000875206

3. At around the same time, I was driving in a narrow street at Brgy. Paliparan, Laurel,
Batangas; when I accidentally hit a parked tricycle on the right side of the car. I stopped the
car and went out to look and know the damaged parts. I found deep scratches from the front
and back door of the right side of the car that hit the steel parts of the tricycle.

4. The scratches caused by the accident cannot be removed or fixed by simple works, buffing
and other ordinary remedial procedures. Restitution of the vehicle to its previous condition
prior to the sustained damages will entail a lot of expenses estimated in the amount shown
in the attached estimate of expenses. Hence, as the owner of the vehicle, I decided to claim
from its insurer.

5. I am executing this Affidavit to attest to the truth of the foregoing and in support of the claim
from the insurer for the repair of the damages caused to the vehicle.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 17 th of October 2022 at

Calamba City, Philippines, with my Non-pro Driver’s License No. N06-19-011685, issued at LTO Las
Pinas, that will expire on November 04, 2023.

JONALYN L. VILLALUZ
Affiant

SUBSCRIBE AND SWORN TO before me this 17th day of October 2022 at Calamba City,
Laguna, Philippines, by the affiant with her above-mentioned Driver’s License No. N06-19-011685 as
competent proof of identity.

Doc. No. ________; ATTY. EMMANUEL E. SANDICHO

Page No. ________;
Book. No. _______;
Series of 2022.
Notary Public Until 31 December 2022
NOTARIAL COMMISSION NO. 19-2021-C
IBP O.R. No. 169038, 01 Jan 2022 (For CY-2021)
PTR O.R. No. CC7894982, 4 Jan. 2022, Calamba City
Roll No. 42246, admitted to the Bar on 9 May 1997
MCLE Compl. Cert. No. VII-00020029 Until 14 April 2025
2ND Floor HK Building, National Highway, Brgy. Halang
Calamba City, Laguna, CALABARZON Philippines