Republic of the Philippines )

_______________________ ) S.S.

AFFIDAVIT

I, OSCAR JR MALANA PUZON, Filipino, of legal age, and a resident of TOW 4 U,

4F, ESCALADES, 20TH AVENUE, SAN ROQUE, QUEZON CITY, after being sworn to in
accordance with law, depose and state: THAT

1. I am a duly licensed driver of my 2019 Nissan Terra 2.5L VE A, Galaxy Black color,
with Conduction No. F1Z-249, Engine No. YD25838808T, and CR No. 35442730-1.

2. On January 5, 2020, I hit a plant box while parking my vehicle, causing a deep dent on
the front bumper.

3. That I am executing this Affidavit to attest to the truth of the forgoing and in support of
my insurance claim for the damage to my vehicle.

FURTHER AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ of _______________

2020, in ___________________, Philippines.

OSCAR JR MALANA PUZON

AFFIANT

SUBSCRIBED AND SWORN to before me this _____ day of _____________

2020 in _______________________.

Doc. No. _______;

Page No. _______;
Book No. _______;
Series of 2020.