Republic of the Philippines)

City Of )s.s
X --------------------------------
AFFIDAVIT OF DAMAGE TO VEHICLE
I, ROBERT YUSON TAN, Filipino, of legal age, married, and presently residing at 109 Apo
St. San Jose Village 3 Binan City, Laguna, after having been duly sworn to in accordance
with law, hereby depose and state:

1. That I am a duly licensed driver with Professional Driver's License No. N03-96-220055
which is valid until 18 September 2023.

2. That I am authorized driver with vehicle with Plate No. UXO 186 registered under the
name of Park Soo Hyun.

3. That on July 11, 2021 at around 12:30am midnight, I was driving and while traversing
Binan - Sta. Rosa National Road, I passed a road construction barrier but did not notice a
protruding steel wire and tried to steer up but I wasn’t able to avoid it. I hit the concrete
barriers which damage my headlight & front bumper and also scraped the left side
portions of the vehicle during this incident.

4. That there were no traffic enforcers at the time of the accident.

5. That I am executing this Affidavit to attest to the truth of the foregoing and in support
of the claim against the insurer for the repair of the damage caused to the vehicle.

AFFIANT SAYETH FURTHER NONE. _____________ at City of Sta. Rosa, Philippines.

IN WITNESS WHEREOF, I have hereunto set my hand seal this____________ Philippines.

ROBERT Y. TAN
Affiant

SUBSCRIBED AND SWORN to before me this _______________, affiant personally

appeared exhibiting to me his Competent Evidence of Identity above stated.

Doc. No.
Page No.
Book
Series of 2021