REPUBLIC OF THE PHILIPPINES}

QUEZON CITY } S.S.

AFFIDAVIT

I, __________________, of legal age, single, and a resident of Quezon

City, after being sworn to in accordance with law, hereby depose and state
THAT:

1. I am a duly licensed driver with Land Transportation Office issued Non-

Professional Driver’s License No. and the same is valid until
September 13, 2022;

2. I am the registered owner of a Starrex Van, which is more particularly

described as follows:

3. On June 20, 2018, at around three o’clock in the afternoon (3:00 P.M),
as I was slowly parking it beside the DOJ Agencies Bldg., I suddenly
sideswiped the pillar of the parking area. As a result, the said vehicle
sustained damage on its right side portion (back seat area);

4. I am executing this Affidavit to attest the truth of the foregoing and in

support of the claim in the insurance for the repair of the damage
caused to the aforementioned vehicle.

IN WITNESS WHEREOF, I hereunto affix my signature this June 21,

2018 at Quezon City.

_________________________________
AFFIANT

SUBSCRIBED AND SWORN to before me this June 21, 2018 at

Quezon City, affiant exhibited to me her Professional Regulation
Commission’s issued ___________, as her competent evidence of identity.
IN WITNESS WHEREOF, I have hereunto set my hand and seal, the
date and place above written.

Notary Public