Republic of the Philippines)

Province of Eastern Samar) S. S.

Municipality of Dolores )

AFFIDAVIT
I, XXX XXX , 16 years old, single, student, presently reside at Barangay 4,
Dolores, Quezon, after having been sworn to an oath in accordance with law, do hereby
depose and say that:
1. I am standing as witness against respondent XXX XXX, driver of the Rusi Motorcycle
with Engine No. RW1575MIKE00342 and Chassis No. RWCLP1B06CE003342
registered under his name. The respondent driver is a holder of Land Transportation
Office Student Permit No. 235855491 valid until October 2, 2015. He is currently
residing in Quezon. The offense was committed under the circumstances narrated
below.
2. On June 22, 2015, at around 6:10 in the evening, I was seating in a motorcycle while
being parked along the side of Dolores Bridge in Barangay Malaintos, Quezon, facing
Barangay Carolina. Seated behind me in the motorcycle was XXX XXX. We were then
enjoying a conversation overlooking the river.
3. A few moments later, we decided to go home as it was already evening. I took myself in
driving the motorcycle while XXX XXX seated behind me. Then I signaled the left rear
lights signifying my intention to proceed to the opposite lane going to XXX XXX. I even
bother to look in the left side mirror to see if there was an incoming motorcycle but the
same was clear.
4. Then I cautiously drove towards the opposite lane going to Dolores Town at moderate
speed. We were already in the opposite lane when suddenly a fast moving motorcycle
driven by XXX XXX from opposite direction bound for Can-avid Town hit and bumped
the left rear portion of our motorcycle directly hitting XXX XXX.
5. As a result of the impact, XXX XXX was tossed into the pavement some meters away.
Fortunately, I was able to hold tight from the motorcycle to avoid from being hurt. When
I regained my composure, I hurriedly approached XXX XXX to help her. She was lying
on the pavement unable to budge herself. She was apparently in excruciating pain
brought about by the incident.
6. Timely, a private tricycle passed by wherein I boarded the injured victim XXX XXX. I
asked the driver of the private tricycle to bring XXX XXX to Dolores Municipal Hospital
for prompt medical attention. I waited in the bridge to prevent XXX XXX from fleeing and
to have his motorcycle guarded. After a while, responding police officers from xxx xxx
arrived in the scene. There, I gave detailed information to the police officers surrounding
the incident.
7. I am executing this affidavit to attest the truth of the foregoing statements and to cause
the filing of a case for RECKLESS IMPRUDENCE RESULTING IN SERIOUS
PHYSICAL INJURIES against xxx xxxx before the Office of the Assistant Provincial
Prosecutor, Dolores, Quezon.
IN TRUTH WHEREOF, I will affix my signature below this 19 th day of July 2016 at
Dolores Municipal Police Station, Dolores, Quezon, Philippines.

XXX XXXX XXX XXX

Affiant

SUBSCRIBED AND SWORN to before me this ___th day of July 2015 in

Dolores, Quezon and I hereby certify that I personally examined the affiant and I am
satisfied that that he fully understand the contents of his affidavit and he voluntarily
executed the same.

XXX XXXX
Assistant Prosecutor II
Administering Officer