Republic of the Philippines )

City of Tacloban ) S.S.

AFFIDAVIT

I, LEODEGARIO C. GERILLA JR., of legal age, Filipino, single, and a resident of

Barangay Guingawan, Tanauan, Leyte, after having been duly sworn to in accordance with the
law, hereby depose and state that:

1.) I am the registered owner of a motor vehicle specifically described as follows:

Make/Series/Year Model : GEELY COOLRAY SPORTS 2022
Engine No. : JLH3G15TDN4BA5604369
Chassis No. : LB37622Z2NX416219
Color : White
Plate No. : HAG2062

2.) I am a duly licensed driver with Driver’s License No. HO2-08-002413 which is valid
until February 18, 2032 issued at Tacloban City, Philippines;

3.) On or about 8 o’clock in the evening of 16 June 2024, I was about to park my car at the
parking area of Sogod Bay Scuba Resort at Padre Burgos, Southern Leyte;

4.) While I was parking my car, I accidentally step on the accelerator and the car continued
until it hit a wall;

5.) Thereafter, I checked and saw that the right passenger side of my car was damaged;

6.) Further, said incident was merely an accident without fault of anybody; and

7.) I am executing this Affidavit to attest to the truth of the foregoing and in support of my
claim against the insurer for the repair of the damage caused to my vehicle during the
aforementioned incident;

IN WITNESS WHEREOF, I have hereunto set my hand this 17th day of June, 2024 in
Tacloban City, Philippines.

LEODEGARIO C. GERILLA JR.,

Affiant
Driver’s License No. HO2-08-002413 valid until 02/18/2032

SUBSCRIBED AND SWORN to before me this 17th day of June, 2024 at Tacloban City,
Philippines, affiant exhibited himself to me his identification card indicated below his name
bearing his photograph and genuine signature as competent proof of his identity pursuant to
the 2004 Rules on Notarial Practice.

Doc No. ___;

Page No. ___;
Book No. I;
Series of 2024.