Republic of the Philippines

In the City of Puerto Princesa

Province of Palawan

)
) S.S
)

AFFIDAVIT
I, ARNEL JAMION IBNO, of legal age, Filipino, married and a resident of Brgy.
Punta Baja, Rizal, Palawan, after having been duly sworn in accordance with law, do
hereby depose and say:
1. That I am the owner of a certain vehicle, which more particularly described as
follows:
MAKE/SERIS
COLOR
CONDUCTION STICKER NO.

: NISSAN NAVARA NP 300

: SAVANNA ORANGE
: OV 3083

2. That on January 24, 2016, around 2:00 PM, I was traversing the road at Sitio
Malaca-laca, Brgy. Campong-Ulay, going to Brookes Point, Palawan, when I
turned on the curve road thereat, I did not noticed a huge rock on my way and
it was too late for me to avoid it for there was also a vehicle on the opposite side
of the road and instead of hitting the said vehicle on the opposite side of the
road, I hit the said rock and resulted to lost my control of the vehicle and
crashed and run over the fence made of barb wire, which cause multiple
damages to the above-described vehicle;
3. That I executed this affidavit to attest to the truthfulness of the foregoing
instrument and to comply with the requirements for insurance claim, and for
whatever legal purpose the same may serve.

IN WITNESS WHEREOF, I hereby sign this affidavit this _____________________

at Puerto Princesa City, Palawan.

ARNEL JAMION IBNO

Affiant
ID No. ________________
Issued by: ____________

SUBSCRIBED AND SWORN to before me this _____________________, at Puerto

Princesa City, Palawan.

Doc No. _______

Page No. ______
Book No. _____
Series of 2016