Republic of the Philippines)

Province of Pangasinan ) s.s.

City of San Carlos )

AFFIDAVIT
I, RODOLFO P. STA ANA, JR., of legal age, single, Filipino and a resident of #22 Caoayan Kiling,
San Carlos City, Pangasinan, after having been duly sworn to in accordance with law do hereby depose
and state:

1. That I am the collector at Ilocandia Fast Cash Corporation, a corporation duly existing and
organized in the Philippines with principal office address at Tripple R Building, Sevilla, City of
San Fernando, La Union;

2. Ilocandia Fast Cash Corporation is the registered owner of motor vehicle, more particularly
described as follows:

Make/Type : Honda MC
Model : 2010
Plate No. : 3351 ZD
Engine No. : XRM16E031985
Chassis No. : XRM16031981

As evidenced by copy of the Official Receipt/Certificate of Registration which is attached

as Annex “A” to form an integral part hereof;

3. That the said motor vehicle is assigned to me as service vehicles for collection purposes of
Ilocandia Fast Cash Corporation;

4. That sometime on June 29, 2012 at around 2:00 o’clock in the afternoon, I was driving the
said motor vehicle along the National Highway at Brgy. Cablong, Sta. Barbara, Panagsinan
when I figured in an accident;

5. That at the time of the incident, I am the holder of a driver’s license issued by the Land
Transportation Office under Professional Driver’s License No. A12-04-000071, a copy of
which is hereto attached as Annex “B” to form an integral part hereof;

6. That the motorcycle sustained damages which are as follows:

PARTS OF THE MOTORCYCLE STATUS

1. Left Flaring Scratch
2. Tail light and Tail Flaring Broken
3. Rear Handle Scratch
4. Right Engine Cover Broken
5. Right and Left Hand Cover Broken
6. Front Finders Broken
7. Passenger Right Foot Cover Broken
8. Headlight Cover Scratch
9. Right Flaring Broken Lock
10. Rear Finders Broken

7. The amount of the damages of the motorcycle is still undetermined;

 8. That I am executing this affidavit to attest to the truth of the foregoing statement
and for the purposes of claiming insurance from the insurer/insurance company.

IN WITNESS WHEREOF, I hereby affix my signature this 26th day of July 2012 at San Carlos
City, Pangasinan.

RODOLFO P. STA ANA, JR.

Affiant
License # A12-04-000071
Expires on 2015-26-5

SUBSCRIBED AND SWORN to before me this 26th day of July 2012 at San Carlos City,
Pangasinan.

Doc No. ___

Page No. ___
Book No. ___
Series of 2012