Republic of the Philippines)

Province of ______..........) S.S.

City of ______..............)
x - - - - - - - - - - - - - - - - - - -x

AFFIDAVIT

I, ____________ Filipino, of legal age, and a resident of Road 6, Milaflor

Village, Brgy.____ City, 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.

__________covered by__________, which is valid until February 07, 2019.

2. That a motor vehicle is owned and registered in the name of my

deceased father Felipe Irinco which is more particularly described as follows:

MAKE :

Motor No. :

Plate No. :

Stock No. :

Serial/Chassis No.:

Model : 2014

3. That sometime in the month of___________, I was asked by my father to

drive the aforesaid motor vehicle to buy something from Super Metro Mall,
Calbayog City;

4. That while I was slowly manuevering to park the car at the parking
area of Super Metro Mall, the aforementioned vehicle suddenly hit the post of
the building and as a result thereof, the said vehicle sustained damage at its
frontal area, specifically the bumper of the car;

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

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

IN WITNESS WHEREOF,I have hereunto set my hand this___________in

___________________ Philippines.

Affiant

SUBCRIBED and sworn to before me in the _______________, Province of

________, Philippines, this ____ day of June, 2019, affiant personally appeared
and having exhibited to me her issued at _______________