Republic of the Philippines )

Quezon City ) S.S

AFFIDAVIT OF DAMAGE TO VEHICLE

I, DEXTER SALAZAR AQUINO , of legal age, Filipino, married, and a resident of 176
La Verna General Ordonez St., City Marikina, Philippines, after being sworn to in accordance
with law, depose and state:

1. That I am a duly authorized licensed driver with Driver's License No. D16-99-
199791 which is valid until 2019-08-29.

2. That on 14 May 2018 at around 11 o’ clock in the morning, after checking out at
Anvaya Cove Golf and Sports Club, Subic at the parking area of said place, I noticed that
the vehicles’ glass front window side sill was broken and there are visible scratches at
the driver’s side.

3. The said vehicle is owned and registered to FREDERICK M. LINSANGAN, my

employer and is more particularly described as follows:

Model: Hyundai Starex Model 2018

Color: Silver Gray
Plate number: 130110 (Conduction Sticker No. U0 Q 100)
Certificate of Registration No.: 296324022
LTO Official Receipt: 1275530830

4. That the security guard on duty declared to having not noticed or heard any incident
causing the said damage to the 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 any possibility that might have 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 the vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this 16th day of May 2018 in
Quezon City, Philippines.

_______________
Dexter S. Aquino

SUBSCRIBED AND SWORN TO BEFORE ME this 16th day of May 2018 in Quezon
City, Philippines by ____________________ who presented his Driver's License No. D16-99-
199791 which is valid until 2019-08-29 issued in Manila, Philippines.

Doc. No. ___

Page No. ___
Book No. ___
Series of 2018.