Republic 

of the Philippines)
Province of Cebu) S.S.
City of Cebu

x–––––––––x

AFFIDAVIT

I, GARCIA, CHERY ANN, Filipino, married/single, and residing at Purok 6, Sitio

San Miguel, Apas Cebu, City, 6000 after having been duly sworn to in
accordance with law, depose and state:

That I am the authorized driver of a White Toyota Rush with Plate No.
GAO4344, owned and/or registered under my name.

That as such, I hold a Non-Proof/Professional Driver’s License No. GOI- 15-

003170 issued at Talibon, Bohol Extension Office and will expire on
November 27, 2022.

That on June 26, 2021 at about six o’clock in the evening while I was carefully
driving the above-mentioned vehicle, the Car Radio Antenna (Shark Fin) of the
said vehicle was snapped by small tree branches causing its damage.

That I am executing this affidavit to attest to the truth of the foregoing and in

support of the claim against my insurer for the repair of the said of the said
damage.

IN WITNESS WHEREOF, I hereunto affix my signature this June 29, 2021 at

Cebu City.

CHERRY ANN GARCIA

AFFIANT

SUBSCRIBED and SWORN to before me this ___________day of

__________________, Cebu City, Philippines.

Doc. No. _____________

Page No. __________________
Book No. ______________
Series of 20 _____________