REPUBLIC OF THE PHILIPPINES)

) S.S.

AFFIDAVIT

That I, DANTE F. DELA CRUZ, of legal age, Filipino Citizen, and with postal address at
#112 DONA AURORA ST. PARANG MARIKINA CITY, after having been duly sworn to in
accordance with law do hereby depose and say:

That I am the driver of that certain motor vehicle which is more particularly describe:

MV FILE NO. :1301-00001370467 BODY TYPE :WAGON

PLATE NO. :P2A024 ENGINE NO. :1NRG012564
COLOR :BLUE MICA MET. YEAR MODEL :2019
SERIES :AVANZA 1.3E AT

1. The incident happened last Saturday, September 21, 2019 at around 8:30 in the evening at
Marikina Sport Center.

2. That when I was about to go back in my car, which is on park, I noticed that my car has
scratched. I don’t even know how it happened and what vehicle hit my car.

This affidavit is executed to certify the facts above stated to inform the proper authorities
concerned and whatever legal purpose this document may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ____________________ in

_____________________;

DANTE F. DELA CRUZ

Affiant

SUBSCRIBED AND SWORN to before me this _________________day

______________________, affiant exhibited to me her Community Tax Certificate No
____________________ Issued at __________________ on __________________ Philippines.

Doc No._______
Page No.______
Book No.______ Notary
Series of 2019