Republic of the Philippines )

Province of Cebu ) S.S.

City of Cebu )

AFFIDAVIT OF DAMAGE TO VEHICLE

I, SHARPAY EVANS, Filipino, of legal age, single, and a resident of Unit 1, Entrada
Residences, Status Quo Ave., Cebu City after being sworn to in accordance with law, depose and state:

1. That I am the registered owner of the vehicle more particularly described as follows:

Model: 2018 Toyota Fortuner

Color: White
Plate number: FABULUS
Certificate of Registration No.: 1999669433
LTO Official Receipt: 5559977654
Chassis No.: MH4LX160CCKP16434

2. That on June 15, 2020, at around 11 o’clock in the morning, my authorized driver, RYAN
EVANS, a duly licensed driver with Professional Driver’s License No. N0122-23434-939
valid until 12 May 2022, was driving the aforementioned vehicle;

3. That while RYAN EVANS was slowly driving along M. Gov. Cuenco Ave., another vehicle
made a sudden change of lane causing him to swerve to the left to avoid hitting with the said
vehicle. However, another motorcycle driven and owned by TROY BOLTON stopped at the
center lane to make a left turn without giving proper signal beforehand, causing a collision
between the Toyota Fortuner and the motorcycle. As a result, the above described vehicle
sustained damages and the parties involved suffered bodily injuries;

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

IN WITNESS WHEREOF, I have hereunto set my hand this 20th day of June, 2020 at Cebu
City, Philippines

SHARPAY EVANS

SUBSCRIBED AND SWORN TO BEFORE ME this 20th day of June 2020 in Cebu City, Philippines by
Sharpay Evans who presented her Philippine Passport No. XY10982392, valid until December 28, 2022,
issued in Manila, Philippines.

ATTY. JUAN SANTOS

Notary Public
Valid until 12-31-20
Roll No. 92327970
MCLE NO. 29373273
PTR No. 39493

Doc. No.12;
Page No. 23;
Book No. II;
Series of 2020.