REPUBLIC OF THE PHILIPPINES )

CITY OF ILOILO ) S.S.

X------------------------X

AFFIDAVIT

That I, ANA S. CELIZ, of legal age, Filipino, married and a resident of

th
305, 8 St., Lawaan Village, Jaro, Iloilo City, Philippines, after having been duly
sworn to in accordance with law, hereby depose and say, THAT :

That my husband, Camilo L. Celiz, is the registered owner of a MAZDA

CX-5, Sky Active, Sport Utility Vehicle, with plate no. FHT 606.

On April 30, 2016 at about 11:30 o’clock in the morning while I was
driving aforesaid vehicle in reverse direction in our garage at home, its rear tire
skid upon hitting a wooden log;

That as a result thereof, the said vehicle incurred dents, scratches and small
hole at the lower right portion of its rear bumper;

That I did not bother to report said incident to the police station, as there was
no third persons involved neither were there injuries sustained as a result of the
said accident;

This affidavit is executed to attest to the truth of the foregoing facts and for
such other legal purpose.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

______________________ at Iloilo City, Philippines.

ANA S. CELIZ

SUBSCRIBED AND SWORN to before me this

________________________ at Iloilo City, Philippines, affiant whose name and
personal circumstances are herein stated, personally appeared before me and
identified by me through her OSCA ID No. 005442, as competent evidence of
identity, presented the foregoing document, signed the same in my presence and
affirmed, under oath, to the correctness of the contents of the allegations thereof.

Doc. No. _______

Page No. _______
Book No. _______
Series of 2016.