September 22, 2016

INCIDENT REPORT

I, ARMANDO J. YAP, Filipino of legal age, married, and employee of ACTIVE ALLIANCE
FINANCE CORP. with office address at Chino Roces Ave., Makati City, hereby depose and
state;
1. That I am duly licensed driver with Professional Drivers License No. C10-10-016169
which is valid until November 20, 2016;
2. That on 21 September 2016, at around 12:30 in the afternoon, I was driving a vehicle,
owned and registered in the name of __________________ which is more particularly
described as follows;
MAKE: Isuzu/Dmax
SERIES:
BODY TYPE:

ENGINE NO:
CHASSIS NO.:
PLATE NO.: AVA 29100

3. That while I was slowly backing out of the parking space between Toyota Vios and
plant Box to park the car at the parking area of Municipality of Sta. Maria, Bulacan,
the aforementioned vehicle suddenly hit the plant box from where I was backing out
and as a result the said vehicle sustained damage at its lower left portion of tail body.
I hereby affix my signature below to attest to the truth of the foregoing statement.

ARMANDO J. YAP