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Republic of the Philippines )

Quezon City ) S.S.

AFFIDAVIT

I, JAY PEE M. VILLANUEVA, Filipino, of legal age, single, and a resident of 15 Macaya Street,
Pasong Tamo, Quezon City, Metro Manila, Philippines, after being sworn to in accordance with law, hereby
depose and state that:

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


Model: 2016 Hyundai Accent 1.4 E MT
Engine No.: G4LCFU513901
Chassis No.: KMHCT41BAGU041646
Color: Sonic Silver
CS No.: MO 9480

2. I am a duly licensed driver with Driver’s License No. N0116031418 which is valid until 14 October 2019;

3. On 2 December 2017, while I was carefully turning at the corner of Congressional Avenue Extension
and Luzon Avenue in Quezon City at around 7:30AM, a speeding red Ford Fiesta suddenly hit the left
side of my bumper causing me to turn the steering wheel to the right where the right side of my bumper
hit a concrete barrier;

4. Because of shock, I was not able to take notice of the plate number of the red Ford Fiesta that did not
even bother to stop after the collision;

5. That I am executing this Affidavit to attest to the truth of the foregoing and in support of the 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 14th day of December 2017 in Quezon City,
Metro Manila, Philippines.

JAY PEE M. VILLANUEVA


Affiant

SUBSCRIBED AND SWORN to before me this ______ day of _________________ 2017 in Quezon
City, Affiant exhibiting to me his UMID card bearing No. 006-0172-8871-8 issued in Quezon City, which does not
have an expiration date.

Notary Public

Doc No. _________;


Page No. ________;
Book No. ________;
Series of 2017.

Republic of the Philippines )


Quezon City ) S.S.

AFFIDAVIT

I, JAY PEE M. VILLANUEVA, Filipino, of legal age, single, and a resident of 15 Macaya Street,
Pasong Tamo, Quezon City, Metro Manila, Philippines, after being sworn to in accordance with law, hereby
depose and state that:

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


Model: 2016 Hyundai Accent 1.4 E MT
Engine No.: G4LCFU513901
Chassis No.: KMHCT41BAGU041646
Color: Sonic Silver
CS No.: MO 9480

2. I am a duly licensed driver with Driver’s License No. N0116031418 which is valid until 14 October 2019;

3. On 13 October 2017, while my brother and I were on our way home at the slanted corner of Macaya
Street and Tandang Sora Avenue in Barangay Pasong Tamo, Quezon City around 9:00PM where the
street was not sufficiently lit, a 10-wheeler truck positioned in front of my car suddenly accelerated back,
almost hitting the front of my car causing me to quickly reverse our car to avoid further damage and
more disastrous collision;

4. Because of the sudden reverse motion, I hit a stacked up oven firewood of our neighbor at the side of
the road which caused scratches on the lower right side of the car;

5. Because of shock, I was not able to take notice of the plate number of the 10-wheeler truck that sped up
ahead even before we could go down the car and confront the truck driver;

6. That I am executing this Affidavit to attest to the truth of the foregoing and in support of the 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 14th day of December 2017 in Quezon City,
Metro Manila, Philippines.

JAY PEE M. VILLANUEVA


Affiant

SUBSCRIBED AND SWORN to before me this ______ day of _________________ 201 in Quezon City,
Affiant exhibiting to me his UMID card bearing No. 006-0172-8871-8 issued in Quezon City, which does not have
an expiration date.

Notary Public

Doc No. _________;


Page No. ________;
Book No. ________;
Series of 2017.

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