REPUBLIC OF THE PHILIPPINES )

Municipality of Hinigaran ) S.S.

AFFIDAVIT OF UNDERTAKING

I, NOLI AGUILLON y Quiroba, of legal age, single, Filipino with postal address at Brgy. San Juan,
Binalbagan, Negros Occidental after having been sworn in accordance with the law hereby depose and state
that:

1. I am the owner of the VEHICLE particularly described below, who figured in an accident,

MAKE: Kawasaki
SERIES: CT125A
BODY TYPE: Motorcycle
YEAR MODEL: 2018
ENGINE NO.: DYYWJC54431
CHASSIS NO.: MD2A76BY8JWC69560
MV FILE NO.: 0601-00000610569

2. On June 15, 2019 at around 8:00 o’ clock in the morning, while I was driving my above-described
motorcycle, I was a party to an accident. I was hit by Eusebio Calunsag y Pellejo who was also driving
his motorcycle. Said road crash incident caused damage on the left front portion of my said motorcycle;

3. As a result of said vehicular mishap, the vehicle that I was driving was impounded by the authorities
(PNP – Hinigaran);

4. I am now requesting that said motorcycle be released in my favor.

5. In line with the said impoundment of my vehicle, I now hereby undertake to produce said vehicle upon
request of the authorities if such will be needed for further proceedings or investigation;

6. This affidavit is being executed to support my request for the release of the impounded vehicle;

7. I am executing this undertaking to attest to the truth of the foregoing.

IN WITNESS WHEREFOR, I have hereunto set my hands this 27th day of December 2019 in HInigaran,
Philippines.

NOLI AGUILLON y Quiroba

Affiant

SUBSCRIBED AND SWORN TO before me this 27th day of December 2019 in Hinigarn, Ahilippines, affiant
Eexhibiting to me his valid proof of identification.

ROMYLEN A. GERMINAL
Notary Public for the City of Himamaylan
And the Municipalities of Binalbagan and Hinigaran
IBP No. 073546 2-7-19 – Pasig City
PTR No. 0001208 1-10-19 – Hinigaran
MCLE No. VI – 0002265 untl 4-14-2022
Roll of Attorney No. 60634
Brgy. Tagda, Hinigaran, Neg. Occ

Doc. No.: 234;

Page No.: 047;
Book No.: IX;
Series 2019.