Republic of the Philippines )

Province of Cagayan ) S. S.
City of Tuguegarao )
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AFFIDAVIT

I, TERESITA U. MARTIREZ, Filipino, of legal age, and a resident of #1 RG Village Phase

31, Ugac Norte, Tuguegarao City Cagayan, after being duly sworn to in accordance with
law, hereby depose and state:

1. That I am the registered owner of Hyundai Tucson 2012 Model with Plate
No. UOI 643;

2. That I am with my son Mr. Jayson Martirez who happens to be the Driver
with a Non- Professional Driver’s License when an incident happened on
February 16, 2019 involving my vehicle;

3. That my vehicle was parked in an area of the Robinsons Mall-

Tuguegarao City, Cagayan when without our knowledge, a certain vehicle
bumped the front portion of my vehicle which resulted to a damage thereon;

4. That also, upon inspection of the vehicle, the right portion of the back of
the vehicle was also damaged when it was parked and to our mind, it was
also dented on the same date and during the said incident;

5. That as a result of such incident, my vehicle incurred damages with

undetermined or unestimated value; and

6. As such, I am executing this Affidavit to attest to the truth of the foregoing

and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 19th day of February
2019 in Tuguegarao City, Cagayan, Philippines.

TERESITA U. MARTIREZ
Affiant

SUBSCRIBED AND SWORN on the date and place above written. The Affiant is
personally known to the Notary Public.

Doc No.
Page No.
Book No.
Series of 2019