REPUBLIC OF THE PHILIPPINES)

BATANGAS CITY ) S.S.

AFFIDAVIT

I, NAIDA C. PABELICO, Filipino, married, of legal age, and a resident of Mataas na Lupa,
San Pascual, Batangas, after having been sworn to in accordance with law, hereby depose and
say THAT:

That I am the registered owner of a motor vehicle more particularly described as: 2013
HYUNDAI I10 with plate number plate number WIK517 with Engine No. G4HGDM621691 and
Chassis No. MALAM51BADM348508;

That the said vehicle is insured by STANDARD INSURANCE CO., INC. (Policy No. SI-PCP-
500016890);

On April 28, 2016 at around 10:30 am, I was driving the said motor vehicle along the Sta.
Rita Road, Batangas. The heavy traffic during that time was caused by the road widening of the
said road. As I was about to move forward I accidentally stepped on the brakes of my vehicle
because the vehicle in front of me suddenly stopped so I applied the brakes on my motorcycle
causing damages to my Hyundai I10 particularly dents on the hood, cracks in the bumper and
scratches from the right passenger side of the said vehicle of still undetermined cost of repair;

I am executing this Affidavit to attest to the truth of the foregoing facts and for
whatever legal intents and purposes it may serve;

IN WITNESS WHEREOF, I have hereunto set my hand this ______________ at Batangas

City.

NAIDA C. PABELICO
Affiant
UMID No. CRN-006-0039-0349-6

SUBSCRIBED AND SWORN to before me, this________________, at Batangas City,

affiant exhibiting to me her Unified Multi-Purpose Identification with number stated above.

ROBERTO IIGO D. SANCHEZ

Notary Public
Until December 31, 2017
Doc No. _____; PTR No. 2576992 01.14.2016 Bats. City
Page No. ____; IBP No. 1011277 01.20.2016 Bats. City
Book No. XI; Roll No. 61644 Serial No. 2016-31
Series of 2016 Zenaida Arcade, 43 M.H. Del Pilar St., Batangas City
MCLE Compliance Certificate No. IV-0015192