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REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ZAMBOANGA DEL NORTE )S.S.


MUNICIPALITY OF SINDANGAN )
X---------------------------------------------------------------/

DRIVERS AFFIDAVIT

I, JUVY MAGLINTE y BANGGOY, Filipino, of legal age, married to GINA TIGLEY


MAGLINTE, and a resident La Roche, San Miguel, Sindangan, Zamboanga del Norte, after having
been duly sworn to in accordance with law, do hereby depose and state:

That I am the driver of a motor vehicle more particularly identified as follows:

MAKE : FORD
YEAR MODEL : 2016
SERIES : EVEREST AMBIENT
PLATE NO : ACP5615
Engine No. : P4AT2143842
CHASSIS NO. : MNCAXXMAWAFP45155
DENOMINATION: SPORTS UTILITY VEHICLE
BODY TYPE : WAGON

That I am the husband of the registered owner of the above-described vehicle who is
GINAH TIGLEY MAGLINTE;

That I was driving the above-mentioned vehicle at home on June 22, 2017 at around 5
oclock in the afternoon. When I was driving the vehicle to my garage, I miscalculated the
distance of the gate and my vehicle, thereby causing an accident wherein my vehicle rear
bumped the gate of my house. I managed to brake immediately when I heard the crashing
sound;

That the above-mentioned incident caused the damage to my vehicle. The damaged
caused was the indentation of the rear portion of the vehicle and the scratches of the paint in
the said portion of the vehicle;

That I am executing this affidavit to establish these facts as to the damage to the car and
in support of the claim for replacement/compensation from the insurer of the said car.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___________ day of


June 28, 2017, at Sindangan, Zamboanga del Norte, Philippines.

JUVY B. MAGLINTE
Affiant
Professional Drivers License No. K12-93-001342 issued by LTO and valid until
07/17/2017
SUBSCRIBED AND SWORN TO BEFORE ME this __________ day of June, 2017, in
Sindangan, Zamboanga del Norte, Philippines affiant exhibiting his competent proof of identity
details of which are written below his name.

DOC. NO. ____________


PAGE NO. ____________
BOOK NO. ___________
SERIES OF 2017.

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