REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI )S.S

AFFIDAVIT OF CAR INCIDENT

I, MARY ANN JUGOS BRIONES, of legal age, Filipino, widow and with
residence address at Unit 7F, 7/F One Valero Square, #4546 Quintos St., Brgy Poblacion,
Makati City, After having been duly sworn to in accordance with law, do hereby depose
and state:

That I am the registered owner of a motor vehicle more particularly described as

follows:
MAKE/TYPE : Mitsubishi/Sedan PLATE NO. : ABD 5980
YEAR MODEL : 2015 CR NO. : 233556934
ENGINE NO. : 3A92-UCS0681 OR NO. : 1760546270
CHASSIS NO. : MMBSTA13AFH016620

That on December 2020, I parked the aforementioned vehicle in our building

parking area I usually park my car. That I miscalculated and accidentally bumped against
the wall. It sustained damage of my rear bumper and left tail light of my driven vehicle;

And, on May 27, 2021, I parked my car along Nicanor Garcia Street (Reposo)
Makati City. When I get back my car, I noticed that there is a dent on the right side of my
driven vehicle;

And, on June 2021, I was driving in reverse in our building garage area. I
miscalculated and accidentally bumped against the wall that dismantle my left side mirror
and destroyed the whole assembly where the mirror is connected;

That the aforementioned situations was an incident beyond my control after

exercising extraordinary care and diligence to safety;

That I am executing this affidavit to attest to the truth of the foregoing facts and for
the purpose of an Insurance Claim in hands of MAA GENERAL ASSURANCE PHILS.
INC., at #146 Valero St., Salcedo Village, Makati City

IN WITNESS WHEREOF, I have hereunto affixed my signature this 11 th day of

June 2021 at the City of Makati.

MARY ANN JUGOS BRIONES

Affiant

Subscribed and sworn to before me this 11 th day of June 2021 at the City of Makati,
and affiant exhibiting to me her Driver’s License ID No. N01-96202936.

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