Republic of the Philippines

City of Tacloban

)
) s.c.
AFFIDAVIT
(Fact of Damage)

I, MIGUEL C. TONIDO, of legal age, married and a resident of 109Brgy. 95 Caibaan Tacloban City, after having been duly sworn to in
accordance with law, hereby depose and say that:
1. I am the registered owner of a motor vehicle particularly described
as:
Make: Isuzu
Series: 2013 Sportivo M
Engine No.: 4JA1M42767
Chassis No.: PABTBR54FC2075326
Plate No.: FJF599
2. On the occasion and by reason of occurrence on November 8, 2013
of Supertyphoon Yolanda which directly hit Eastern Visayas, the
above-mentioned motor vehicle was struck by strong winds and
heavy rains thus sustaining visible dents and scratches and was
further inundated in floodwater categorized as Flooded Level B.
3. In view of the said damage to the above-mentioned motor vehicle, I
am now filing a claim against our insurer under Malayan Insurance
Policy No. V0216000/ V0216063;
4. I am executing this Affidavit (Fact of Damage) in support of our
above-captioned claim against our said insurance company.
IN WITNESS WHEREOF, I have hereunto set my hand this 29 th day
of January 2014 at Tacloban City, Leyte, Philippines.

MIGUEL C. TONIDO
Affiant
SUBSCCRIBED AND SWORN to before me this 29 th day of January
2014 Tacloban City, Leyte, Philippines, by affiant exhibiting to me
his LTO Drivers License No. N03-84-042599 issued by LTO Tacloban
valid until 2013-05-08.

ATTY. JO ANN YU BALAGA

Notary Public
Until December 31, 2014
Notarial Commission No. NC-2013-05-80
2/F Rm. 007 S&A Realty Bldg.
221 Avenida Veteranos, Tacloban City
Attorneys Roll No. 62045
IBP No. 955330 01/10/2014; Leyte
PTR No. 7105186 01/06/14; Leyte