Republic of the Philippines )

City of Butuan ) S.S.

AFFIDAVIT OF DAMAGE TO VEHICLE

I, NOEL R. JAPITANA, of legal age, Filipino, married, and a resident of Princess

Homes 2, Villa Kananga, Butuan City after being sworn to in accordance with law,
depose and state:

1. That I am a duly licensed driver with Driver's License No. K01-98-037782

which is valid until December 29, 2023.

2. That I am the registered owner of a motor vehicle which is specifically

described as follows:

MODEL : TOYOTA AVANZA 2013

MOTOR NO. : DL84007
CHASSIS NO. : MHKM1BF2FBK001579
COLOR : DARK STEEL MICA
PLATE NO. : KGR-392

3. That said motor vehicle figured in an unfortunate incident on June 23, 2019 at
about 10:36 A.M. while I was driving it along 1st Street, Guingona
Subdivision, Butuan City. When I turned right in one of the intersection, I
was not able to notice a big rock at the roadside which hit the right rear door
thus causing damage to the lower part of the aforementioned door which
resulted to a considerable damage to my said vehicle.

4. That I am executing this Affidavit to attest to the truth of the forgoing and in
support of the claim with the insurer for the repair of the damage caused to
my vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this 2 nd day of July 2019 in
Butuan City, Philippines.

NOEL R. JAPITANA
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this 2 nd day of July 2019 in Butuan City,
Philippines by the Affiant who presented his Driver's License No. K01-98-037782, valid
until December 29, 2023, issued in Butuan City, Philippines.

Doc. No. ______;

Page No. ______;
Book No. III
Series of 2019.