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Republic of the Philippines )

Province of La Union ) s.s.

Municipality of Naguilian )


I, JANET R. ESTEPA, of legal age, single, Filipino citizen and a resident

of Gusing Norte, Naguilian, La Union, after having been sworn to on oath in
accordance to law, hereby depose and state that:

1. I am the authorized driver of a motor vehicle, particularly a Mitsubishi

Lancer with plate number DNI98;

2. However, on 12 June 2018, said motor vehicle incurred damages on

the left side of its bumper when I accidentally ran over a boulder;

3. I am executing this affidavit to attest to the truth of the foregoing

facts particularly for insurance claims to defray the expenses incurred
for the repair of the said motor vehicle;

4. Further, I am executing this affidavit in good faith and in accordance

to law.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 7th

day of July 2018 in Naguilian, La Union, Philippines.

Driver’s License No. A15-01-003474

SUBSCRIBED AND SWORN TO BEFORE ME this 7th day of July 2018 in Naguilian, La
Union, Philippines, by the affiant who is known to me on the basis of competent document
shown as proof of her identity.