(Republic of the Philippines )

(Province of Surigao del Norte ) Sc.

AFFIDAVIT

I, JEREMY C. GEMPARO, Filipino, of legal age, married, and a

resident of Purok 5, Brgy. San Juan, Surigao City, Philippines, after being
sworn to in accordance with law, depose and state:

1.That I am the owner of one unit of Ford Everest, color black,

bearing Plate No. CI R547, with O.R. No. 1502957481 and C.R. No.
335603774;

2. That on December 11, 2019, while I was driving the said vehicle
en route to Butuan City, I accidentally bumped into a Honda XR150
motorcycle, hitting its rear portion;

3. That I was clothed with a valid Driver’s License at that time and
that the said vehicle was covered by an insurance with Standard Insurance
Company;

4. That immediately thereafter, a police officer responded to the

place of incident and conducted an investigation thereat;

5. That I and my wife went to the nearest hospital for an immediate

check-up. And as we were invited by certain police authorities to go to
Cabadbaran Police Station, I was interrogated by one of the police officers.
Then, I asked for a copy of their Traffic Accident Investigation Report
(TAIR for brevity);

6. That when we reached home, I was surprised when I noticed

some discrepancies regarding the time of incident as stated in the said
TAIR, to wit:

“PLACE, TIME AND DATE OF INCIDENT:

National Highway, Purok-2, Barangay Comagascas, Cabadbaran
City at about 12:10 PM of December 11, 2019;

FACTS OF THE CASE:

Investigation revealed that at about 4:00PM…” (emphasis ours)

7. That when I reported the fact of incident to Standard Insurance

Company, I was advised to execute an Affidavit regarding the discrepancy
about the time of incident;

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 8. That I hereby confirm that the correct time of incident was
12:10PM of December 11, 2019 and not 4:00PM of the same date;

9. That I am executing this Affidavit to attest to the truth of the

forgoing, to support my application for insurance claim with Standard
Insurance Company for the aforedescribed vehicle and for whatever legal
purpose it may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand this 7 th day

of January, 2020 in Surigao City, Philippines.

JEREMY C. GEMPARO
AFFIANT

SUBSCRIBED AND SWORN to before me this 7 th day of January,

2020 at Surigao City, Philippines. I further certify that I personally
examined the affiant, has ascertained to some prudent degree that he fully
understood the contents, implications and effects thereof, and executes the
same free from whatever form of compulsion other than his own free act
and will.

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