REPUBLIC OF THE PHILIPPINES)

Province of Leyte ) S.S.

Municipality of Villaba )
x------------------------x

JOINT AFFIDAVIT OF TWO DISINTERESTED PERSONS

(OF MOTOR VEHICLE ACCIDENT)
We, GERMAN B. RODANAS and EMILIO D. LUBIANO, both of legal age, married,
Filipinos and residents of Brgy. Liberty, Hilongos and Brgy. Libagong, Villaba, respectively, both
in the Province of Leyte, Philippines, having been duly sworn to in accordance with law, hereby
depose and state:

1. That we personally know the person of GERALD N. VEQUIZO, OIC-Engineer III of

CENRO - Albuera, having been his co-workers in the same office;

2. That GERALD N. VEQUIZO is a duly licensed driver with Professional Driver’s

License No: H12-10-001367, which is valid until November 3, 2018;

3. That while we were on our way from Leyte, Leyte to our office in CENRO – Albuera
(and still on official duty) on June 16, 2017 at around 10:40 o’clock in the evening,
said GERALD N. VEQUIZO met an accident in Poblacion Road, Albuera, Leyte,
Philippines;

4. That because of said accident, GERALD N. VEQUIZO was admitted to the Ormoc
Doctors’ Hospital, Ormoc City, Leyte, where he spent a total amount of ₱200,000.00,
more or less, for the surgical and medical expenses;

5. That we are executing this affidavit to declare the truth of the foregoing facts and to
support GERALD N. VEQUIZO’s claim for insurance with the Government Service
Insurance System (GSIS).

6. This Affidavit is likewise executed for whatever legal purpose/s that it may serve.

IN WITNESS WHEREOF, we have hereunto set our hands this 17th day of July, 2017 at
Villaba, Leyte, Philippines.

__________________________ _____________________________
GERMAN B. RODANAS EMILIO D. LUBIANO
AFFIANT AFFIANT

SUBSCRIBED AND SWORN to before me, this 17th day of July, 2017, by GERMAN B.
RODANAS who exhibited his Professional Driver’s License Card No.: G03-98-042866 on October
23, 2015 (and expires on 10/23/2023) at LTO – Maasin City, Leyte and by EMILIO D. LUBIANO
who exhibited his Non-Professional Driver’s License Card No.: H09-17-000798 issued on May 9,
2017 (and expires on June 12, 2021) at LTO – Carigara, Leyte , both of whom are personally known
to me (or whom I have identified through competent evidence of identity).

NOTARY PUBLIC
Doc. No. ______;
Page No. ______;
Book No.______;
Series of 2017.