REPUBLIC OF THE PHILIPPINES )

CITY OF ILOILO ) S.S.

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

AFFIDAVIT

That I, JEANETTE B. BARRANCO, of legal age, Filipino, married and a resident of

Block 14, Lot 30, Alta Tierra Village, Jaro, Iloilo City, Philippines, after having been duly
sworn to in accordance with law, hereby depose and say:

That I am registered owner of a motor vehicle, a 2017 TOYOTA FORTUNER, with

Engine No. 2GDC082585, Chassis No. NMHFGB8GS3G0818156 and with Plate No.
ADM8992;

That on April 6, 2018 (Friday) at about 10:00 o’clock in the morning, I parked said
motor vehicle at the vicinity of MEDICUS Medical Clinics, Diversion Road, Mandurriao, Iloilo
City, with the intention of going to my medical clinic located thereat to attend to my patients;

When I returned an hour thereafter, I noticed that the rear bumper of my TOYOTA
FORTUNER was damaged, further verification thereafter reveals that there were damages at its
rear bumper cover, rear bumper lower cover, rear bumper cover retainer, rear bumper clips and
backing sensor;

Curios of what happened, I tried to investigate with the people within the vicinity, but
nobody from among them can give me information as to who or what could have caused the
damages to my vehicle; I just presumed that my motor vehicle was bumped from behind and
that the perpetrator just left to evade investigation;

That I did not bother to report the incident to the police authorities, as I don’t have
knowledge what was the cause or who could have caused the damages to my motor vehicle,
coupled with the fact that nobody was injured as a result of the said accident.

That I am executing this affidavit 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.

JEANETTE B. BARRANCO

SUBSCRIBED AND SWORN to before me this __________________________ at

Iloilo City, Philippines. The affiant whose name and personal circumstances are stated above,
appeared in person before me and known to me through her Non-Prof. Driver’s License No. F03-
01-140454, with expiry date, 2019-03-18, as Competent Evidence of Identity, presented the
foregoing document, signed the same in my presence, and affirmed or swore, under-oath to the
correctness of the contents of the allegations thereof.

Doc No. _______

Page No. _______
Book No. _______
Series of 2018.