REPUBLIC OF THE PHILIPPINES)

CITY OF ROXAS . . . . . . . . . . . . . .) S.S.

AFFIDAVIT
I, JOSEPHINE C. CASIPE, of legal age, Filipino, and a resident of Cabugao, Roxas
City, Capiz, subscribing under oath, depose and state:
1. That, I am the owner of a motor vehicle, by virtue of a Deed of Sale, the same
being more particularly described as follows:
Engine No:
Chassis No:
Series:
Body Type:
Year Model:
Plate No.:

K24Z1-2805742
MRHRE48408P020566
CR-V
WAGON
2008
ZRH291

2. That, on October 1, 2015, while I was driving in the highway, along Ivisan, Capiz,
there was a portion of this cemented road which is unfinished and there is a
difference between the cemented road and the loose soil which I did not notice;
3. That, by reason of the sudden fall of the front and rear tires of the car, the rear
bumper forcefully hit the ground causing damage underneath the rear bumper of
the car:
4. That, I execute this affidavit to attest to the truthfulness of the foregoing facts.
IN WITNESS WHEREOF, I have hereunto affixed my signature this
_____________ at the City of Roxas, Capiz, Philippines.
JOSEPHINE C. CASIPE
Affiant

SUBSCRIBED AND SWORN TO before me, a Notary Public commissioned in

and for the City of Roxas, Province of Capiz, Philippines, this
__________________________ by the affiant who has satisfactorily proven to me her
identity through her UMID ID CRN NO. 0003-9273588-9, bearing photograph
and her signature, and that she is the same person who appeared and signed the
foregoing Affidavit in my presence within my jurisdiction, and who avowed to the truth of
its contents under the penalty of law.
Doc. No.: ______;
Page No.: ______;
Book No.: ______;
Series of 2015.