AFFIDAVIT OF VEHICLE DAMAGE

I, Antonio Malazarte, of legal age, Filipino citizen, and a resident of P-7 Amabahan Cabayawa
Tubay Agusan del Norte, after being sworn to in accordance with law, depose and state that:

1. I am a duly licensed driver with Driver’s License No. K14-17-001969;

2. I am an authorized driver of Ford Everest with plate no. ZAA 6448 which is owned by
my daughter Shime-a Malazarte

3. Last September 5, 2019, at about 2:30 in the afternoon, as I parked the car in a
designated parking lot in a store a in Cabadbaran City. I went inside the store, after
that I went back to the car and I noticed that the two back lights of my car was
already busted and dent all over it.

4. I am executing this Affidavit to attest to the truth of the foregoing facts and in
support of my claim against the insurer for the repair of the damage cause to said
vehicle and for all legal purposes it may serve.

IN WINTESS WHEREOF, I have hereunto set my hand this __________

Day, in Cabadbaran City.

Affiant,

Antonio Malazarte