REPUBLIC OF THE PHILIPPINES }

DONE: IN THE CITY OF BAGUIO } S.S.

X ======================== X

DRIVER’S AFFIDAVIT

I, PAULFRED TOMBALI, single, of legal age, Filipino citizen, with residence and postal
address at #462 Maria Pucay, Pinsao Proper, Baguio City, after having been sworn to in accordance
with law, hereby depose and state:

1. That I am the true and registered owner of a certain motor vehicle particularly described
as:

MAKE/TYPE ………………… MITS. Pick-up

MOTOR NO…………………. 4M41-UCAF4226
CHASSIS NO…………………. MMBJRKB808D001885
PLATE NO…………………….. ZKN-911

2. That sometime on 28 July 2010 at about 1:00 P.M., I was driving the said motor vehicle
along Harrison Road, Baguio City at the vicinity of the Bank of Philippine Island.

3. That after two (2) minutes of the said time, when it was our turn to cross the intersection
because the traffic lights read green, a black-colored Toyota Corolla Sedan with plate no.
AYH 242, recklessly came from Lower Mabini St. and tried to beat the red light.

4. That unfortunately, said vehicle suddenly hit the front right fender of my car which
dilapidated it.

5. That I am executing this affidavit to attest to the truth of the foregoing facts and
statements for all legal intents and purposes and to support my insurance claim with
General Pilipinas Insurance Company.

IN WITNESS WHEREOF, I have hereunto set my hand this 26 th day of February 2011, in the
City of Baguio, Philippines.

PAULFRED TOMBALI
Affiant

SUBSCRIBED AND SWORN to before me in the City of Baguio this 26 th day of February 2011,
by Paulfred Tombali, who has satisfactorily proven his identity through:

Paulfred Tombali, with Passport No. XX81283, valid until February 14, 2016.

who personally know the principal, to be the same person who executed and personally signed the
foregoing affidavit before me and acknowledged that he executed the same.

LIYA ORTEGA-RODRIGUEZ
Notary Public
Until December 31, 2012
Doc. No. __ 24__; PTR No. 050183/Baguio City/01-11-11
Page No. __5___; Roll of Atty. No. 8121983
Book No. I ; IBP Lifetime Membership No. 9031984
Series of 2011. Baguio-Benguet