REPUBLIC OF THE PHILIPPINES)

) S.S.

AFFIDAVIT OF CAR DAMAGE

I, PAUL BAUTISITA, of legal age, Filipino and a resident of

________, after having been sworn to in accordance with law, hereby
depose and say that:

1. That I am the Authorized Driver of an L-300 Mitsubishi Van

registered in the name of ______________, more particularly described
as follows:

MAKE : MITSUBISHI
SERIES : ____________
PLATE NO. : AFA 1473
ENGINE NO. : ____________
MV FILE NO. : ____________
CHASSIS No. : ____________
YEAR MODEL: ____________

2. That on January 2, 2020 at 3:30 in the afternoon, I

accidentally hit the vehicle of Mr. Genaro Oyro while driving. Such
resulted to the damage of the ________ portion of the said vehicle,
copies of photographs of the damaged portions are hereto attached as
Annex “A.”

3. That I am executing this affidavit to attest to the truth and

veracity of the foregoing facts and for whatever legal purpose this
Affidavit may serve;

4. Affiant further sayeth naught.

I have hereunto affixed my signature this ____ day of ___________

2020, at ______________, Philippines.

PAUL BAUTISITA
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of

___________ 2020, at ______________, Philippines, affiant exhibiting to me
his ______________ ID bearing the numbers _____________ as competent
evidence of his identity.

Doc. No. _____;

Page No. _____;
Book No. ______;
Series of 2020.