Republic of the Philippines}

City of Davao }S.S

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AFFIDAVIT OF ACCIDENT

I, ELEANOR M. QUILANETA, of legal age, married, Filipino and

resident Of 2ND K of C Pass Sto. Rosario St., Buhangin, Davao City, after having
been duly sworn to in accordance with law, hereby depose and say that;

1. I am duly registered owner of motor vehicle named below;

MV File No. : 1112-00000331962

Chassis Number : MNBJXXARJJBD44304
Engine No : TSJABD44304
Body : HATCHBACK
Make : FORD
Plate No. : LHA662
Model Year : 2011

2. That on August 4, 2014 at about 8:00 am, I went to Sta. Ana Wharf to
perform boarding formalities on foreign vessel which called at the port of
Davao. I hit a concrete barrier while parking my car which resulted damage on
the right side of the bumper.

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

and for whatever legal purposes it may serve.

IN WITNESS WHEREOF, We have hereunto affixed my signature this

August 8, 2014 in the City of Davao Philippines.

ELEANOR M. QUILANETA
Affiant

SUBSCRIBED AND SWORN to before me this August 8, 2014 in the City

of Davao. Affiant personally appeared and showing to me her Driver’s License
No.L02-95-104924.

RENE D. DE MANUEL JR.

Doc No.08; NOTARY PUBLIC
Page No.02; For & In the City of Davao
Valid Until December 31, 2015
Book No.36; Roll of Attorney No. 53431
Series of 2014 PTR No. 3809200 12-18-13
IBP No. 847487 12-3-13
Commission Serial No. 106-2014