Republic of the Philippines)

City of Davao ) s.s

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AFFIDAVIT OF INCIDENT

I, EUFRACIO C. UY, Filipino, of legal age, married, and a resident of L1, B1, Donasville Subd.,
Davao City, after having been sworn to in accordance with law, do hereby depose and state that:

1. That I am the authorized driver of that motor vehicle registered under the name of my son-in-
law, Generoso H. Galvez Jr., which vehicle is specifically described as follows:

MAKE : Hyundai
PLATE NO. : AAG 7902
MODEL : 2014
SERIES : Santa Fe 2.2LR
PLATE NO. : XV3017
ENGINE NO. : D4HBDU900227
CHASSIS NO. : KMHSUB1XBEU251459

2. On July 9, 2016 at around 12:15 in the afternoon, while I was backing along the highway at
Brgy. Lago, Glan, South Cotabato, I accidentally sideswiped the railing/barrier on the said highway, which I
did not see from the rearview and side mirrors;

3. The impact caused a dent and scratch on the right side of the above described motor vehicle,
particularly damaging the front and rear doors thereof, and also caused a scratch on the right step-board,
rear right side skirt, and rear right wheel rim of the said motor vehicle;

4. I am executing this affidavit to attest to the truth of the foregoing circumstances, for purposes
of claiming against the said motor vehicles insurance, and for whatever legal purpose this may serve.

IN WITNESS HEREOF, I have hereunto set my hands this 11 th day of July 2016 at Davao City,
Philippines.

EUFRACIO C. UY
Affiant
Valid ID: LTO Drivers License No: L06-63-001925

SUBSCRIBED AND SWORN to before me in the City of Davao this 11 th day of July 2016, by affiant
who exhibited to me competent evidence of his identity, that he is the same person who personally signed
the foregoing affidavit before me and acknowledged that he executed the same.

NOTARY PUBLIC

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Series of 2017