Republic of the Philippines)

Cagayan de Oro City) S.S

AFFIDAVIT

I, , Filipino, of legal age, married, and a resident of JB Farms –

Cagniog, Surigao 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., which is

valid until April 4, 2022;

2. That on___________, at around_______, I was driving a motor

vehicle owned and registered by Bank of Commerce which is more
particularly described as follows:

Make: Toyota Motor No.: 2GDC386869

Series: Hilux 2.4L 4x2 Chassis No.: MR0GB8DD7J1415690

Body Type: Pick-Up Plate No.:

Year Model: 2018 MVRR No.: 1001-00000319124

3. That while I was slowly backing out of the parking lot of, the
aforementioned vehicle suddenly hit the chain-post from where I was
backing out and as a result the said vehicle sustained damage at its
right fender;

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

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

IN WITNESS WHEREOF, I hereunto set my hand this

_______________ in Cagayan de Oro City, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this

_________________ in the City of Cagayan de Oro, Philippines, affiant
exhibiting to me his Competent Evidence of Identity in the form of his
Driver’s License No..

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2018.