Republic of the Philippines)

Dumaguete City )
Negros Oriental

Driver’s AFFIDAVIT

I, BERNARD RIVERA GAJUNERA, of legal age, Filipino, married, and

a resident of Barangay Bantayan, Dumaguete City, Negros Oriental,
after having been duly sworn to in accordance with the law, do
hereby depose and state that:

1. I was driving the brand new car, grey Toyota Wigo 2024
model;
2. This car is for registration;
3. That sometime last February 2, 2024, at around 10
AM, somewhere in San Jose St., Dumaguete City;
4. I parked the said car, so I can go to Lee
Plaza to buy something;
5. When I came back, I was shocked to see that the left,
rear head light was broken;
6. For purposes of fixing the damage on the car, I am
executing this Driver’s Affidavit in order to attest
to the truth of the foregoing circumstances and for
the purpose of reporting the damage on the car for the
insurance.

WITNESS WHEREOF, I have hereunto set my hand this 3rd day of

February 2024 in Dumaguete City, Negros Oriental, Philippines.

BERNARD RIVERA GAJUNERA

Affiant

SUBSCRIBED AND SWORN to before me this 3rd day of

February 2024, affiant exhibited his Philippine Driver’s License
with ID No. G02-84-009352, I hereby certify that I have
personally examined the affiant and that he has fully convinced
that he understood the contents thereof and he has executed the
same freely and voluntarily.

DONNA MARIE B. OMOSO, J. D.

Notary Public until 12/31/2025 for
Dumaguete, Sibulan, Bacong, Valencia, Dauin, Zamboanguita, Siaton, all of
Negros Oriental
Notarial Commission No. 2024-002
Roll of Attorney’s No. 76541
IBP OR No. 388914-01/02/2024
MCLE: New Lawyer admitted on May 5, 2022
PTR No. 1233677A-01/02/2024
For the current year of 2024
All of Dumaguete City, Negros Oriental
Cell No. 09171575626
Emailaddress:donnamariebollos1@gmail.com
Doc No. 06
Page No. 03
Book No. 01
Series of 2024

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