REPUBLIC OF THE PHILIPPINES )

CITY OF ILOILO ) S.S.

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

AFFIDAVIT

That I, CELESTE B. SUBALDO, of legal age, Filipino, married and a

resident of Block 14, Lot 5, Deca Homes, Pavia, Iloilo, Philippines, after having
been duly sworn to in accordance with law, hereby depose and say, THAT :

That my husband, Hernan Subaldo, is the registered owner of a Chevrolet,

with plate no. ABM 3241.

On April 30, 2019 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 steel gate;

That as a result thereof, the said vehicle incurred dents, scratches, damages
at the and front lower bumper 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.

CELESTE B. SUBALDO

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 Driver License No F09-17-004481, 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 2019.