Republic of the Philippines )

Province of Cagayan ) S. S.
Tuguegarao City )
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AFFIDAVIT

I, DENNIS J. CONCEPCION, Filipino, of legal age, married, and a resident of Ugac Sur, Tuguegarao
City, Cagayan after being duly sworn to in accordance with law, hereby depose and state:

1. That I am the driver of Honorable Board Member Cristopher T. Barcena of the First District
of Cagayan;

2. That on June 04, 2018 at around 4:45 in the morning, a vehicular accident transpired
along the Maharlika Road, Barangay Catotoran Sur, Camalaniugan, Cagayan;

3. That there are three vehicles involved in the incident and one of which is driven by the
undersigned, a TOYOTA INNOVA with conduction sticker A1J293, Engine Number
1GDO335537, Chassis Number PA2CA8EM2H0030665, color gray registered under the
name of the Provincial Government of Cagayan;

4. That in the excerpt of the Police Blotter, a copy of which is hereto made integral part of
this Affidavit as Annex “A”, the incident happened when the three vehicles were in convoy
on their way to Aparri, Cagayan;

5. That the first vehicle and being tailed by another vehicle suddenly made a full stopped in
order to avoid an on-going road construction which made the last vehicle collided on the
second vehicle;

6. That in order to avoid the impending accident, I maneuvered the steering wheel to the
other side of the road, but despite such, the vehicle side swept the second vehicle which
resulted to some damages to the three vehicles; and

7. That I am executing this Affidavit to attest the truthfulness of the foregoing and in support
of the claim for the insurance of the said vehicle.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 18th day of June 2018 in
Tuguegarao City, Cagayan.

DENNIS J. CONCEPCION
Affiant

SUBSCRIBED AND SWORN to before me this ______day of June 2018 in Tuguegarao City, Cagayan.
Affiant exhibiting government issued Identification Card as proof of his identity.

Doc No.
Page No.
Book No.
Series of 2018