Republic of the Philippines)

Province of Cagayan
) S.S.
Tuguegarao City
)
x--------------------------------------x

AFFIDAVIT
I, CYR ANTHONIE LASAM, of legal age, married, Filipino and
resident of ________________________, under oath, do hereby depose and
say:
1.

That I am a driver/ messenger of the Department of

Health Regional office II located at Maharlika Highway,
Carig, Tuguegarao City;

2.

That on 17 August 2015 at around 8 p.m. while driving

service vehicle Mitsubishi Strada GLS with plate no. AHA
9196 and while traversing the national highway of San
Mateo, Isabela, a stray dog suddenly crossed the road
which prompted me to evade it by swerving the vehicle at
the opposite lane. I lost control of the steering wheel
which caused the vehicle to run in the waterway and
subsequently bumped several malunggay trees.

3.

Because of the accident, the aforesaid service vehicle

sustained several damage on the following parts:
a. Headlamp support panel, pillar post panel;
b. Front end chassis cross member;
c. Hood panel, hood lock latch;
d. Radiator grille;
e. Bumper reinforcement;
f. Bumper face;
g. Skid plate;
h. Head lamp;
i. Head lamp support
j. Fender panel;
k. Hood panel;
l. Door panel;
m. Door hinge;
n. Bracket corner bumper
o. Shield kit splash
p. Intercooler assy., radiator assy.,cooling fan

4.

That there is a need to carry out necessary repairs on the

service vehicle with an estimated amount of THREE
HUNDRED TWENTY ONE THOUSAND SIX HUNDRED
SEVENTY NINE PESOS AND FIFTY TWO CENTAVOS
(PHP 321,679.52) as per estimate of FREEWAY MOTOR
SALES OF CABANATUAN CORP, the servicing company of
the above-mentioned service vehicle.

5.

I am executing this affidavit to attest the truth of the

foregoing for whatever legal purpose it may serve;
AFFIANT FURTHER SAYS NAUGHT.

IN WITNESS WHEREOF, we have hereunto set our hands, this

_________________________ at Tuguegarao City, Cagayan.
CYR ANTHONIE LASAM
(Affiant)

SUBSCRIBED
AND
SWORN
TO
BEFORE
ME
this
_______________________________________________, affiant exhibited to me his ID
with
No.
______________
issued
at
__________________________on
___________________________________.

NOTARY PUBLIC

Doc No. _____;

Page No. _____;
Book No. _____;
Series of 2015