Republic of the Philippines)

Quezon City) S.S

AFFIDAVIT OF DAMAGE TO VEHICLE

I, MEDIO Y. SUERTE, of legal age, Filipino, married, and a resident of

Cabangcalan, Mandaue City, Cebu, Philippines, after being sworn to in
accordance with law, depose and state:

1. That I am a duly licensed driver with Driver's License No. XOXO12345

which is valid until 11-03-2018.

2. That on October 29, 2015 at around 10:00 A.M., after getting out from
my tutorial session at English Only Please Tutorials in Plaza Sugbo, Paseo
Trinidad, Gorordo Avenue, Cebu City, I noticed many visible surface scratches
on the front bumper of my Ford Ranger at the drivers side near the fender,
at the parking area of said plaza.

3. The said vehicle is owned and registered in my name and is more

particularly described as follows:

Model: Ford Ranger Model 2015

Color: Silver Gray
Plate number: ABC6789
Certificate of Registration No.: 143445678
LTO Official Receipt: 99783BHGAH0

4. That the security guard on duty declared to having not noticed or heard
any incident causing the said damage to my vehicle while it was in the parking
lot. Neither was there a CCTV recording in the area which can determine who
caused the damage, as such, I do not foreclose the possibility that it was
another vehicle who caused said damage.

5. That I am executing this Affidavit to attest to the truth of the forgoing

and in support of the claim with the insurer for the repair of the damage
caused to my vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this 13th day of

June 2017 in Quezon City, Philippines.

MEDIO Y. SUERTE
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this 13th day of June 2017 in

Quezon City, Philippines by Medio Y. Suerte who presented her LTO Drivers
License with number , valid until December 28, 2021, issued in Manila,
Philippines.

Doc. No. 420

Page No. 84
Book No. XXXVI
Series of 2017.