REPUBLIC OF THE PHILIPPINES)

CITY OF CAGAYAN DE ORO ) S.S.

AFFIDAVIT

I, ________________, of legal age, married, Filipino and a resident

____________________, after having been duly sworn to an oath in accordance
with law, hereby depose and state:

Last ____________, at about 9:30 o’clock in the morning, I went to

_____________________ to attend o_____________________. I parked my
Everest Titanium Wagon with _______________ at its parking lot. When I
returned to where I parked my vehicle about an hour later, I noticed that on the
front hood, left front of the bumper, and left rear of the bumper were deep
scratches;

I asked the people around if they’ve seen anything or anybody who may
have caused the same, but to no avail;

I am executing this affidavit to attest to the truth of the foregoing and for
whatever purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

______________________ in Cagayan de Oro City.

______________________
Affiant

SUBSCRIBED AND SWORN to before me this

______________________, affiant is exhibited to me his Professional Driver’s