REPUBLIC OF THE PHILIPPINES

Province of Negros Occidental) S.S.

City of Bacolod)

AFFIDAVIT
I, MA. ELENA A. RIVERA, of legal age, married, Filipino, with residence at Purok
Sampaguita 3, Raymund Street, Barangay Singcang-Airport, Bacolod City, Negros
Occidental, after having been duly sworn to in accordance with law, do hereby depose
and state the following:

1. That I am an authorized agent of Standard Insurance;

2. That I caused the payment of the Insurance Policy of EMILIO B. ABUNDO and
JOSE VICENTE GUATELARA;

3. That an erroneous entry appeared in the Policy Schedule of EMILIO B.

ABUNDO, that instead of EMILIO B. ABUNDO as the insured, an entry of EMILIO
B. ABUNDO &/or JOSE VICENTE GUATELARA appeared therein as the insured;

4. That the facts and circumstances surrounding the erroneous entry are as
follows:

a) That a commission was granted to the undersigned when I introduced

and caused the insurance of Jose Vicente Guatelara in my capacity as
agent of Standard Insurance;
b) That the commission I received from the Insurance of Jose Vicente
Guatelara was used to pay the Insurance Policy of the vehicle of EMILIO
B. ABUNDO;
c) That the cashier of Standard Insurance might have probably erred in
appreciating the payment scheme and entered the names of the two
persons with whom I stood as an agent;
d) That the erroneous entry by the cashier caused the other documents to
bear the names EMILIO B. ABUNDO &/or JOSE VICENTE GUATELARA for
the insured;

5. That the erroneous entry was brought about by mere inadvertence and
excusable neglect, and is not in anyway intended to defraud any person or
government institution;

6. That I am executing this affidavit to attest to the truth of the foregoing and for
whatever legal purposes that this statement may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this _____ day of

_____________, 2018, in the City of Bacolod, Philippines.

MA. ELENA A. RIVERA

AFFIANT

SUBSCRIBED AND SWORN to before me, this _____ day of ______________,

2018, by MA. ELENA A. RIVERA, who exhibited to me her
_________________________ issued at Bacolod City, Philippines.

Doc No. _______

Page No. _______
Book No. _______
Series of 2018