Republic of the Philippines )

City of Iloilo……………… ) S.S.

x------------------------------x

AFFIDAVIT

I, MYLES ADAM U. CHUANG, of legal age, Filipino, single, and a resident of

Brgy. Sto. Nino Sur, ARevalo, Iloilo CIty, Philippines, under oath respectfully manifest,
that:

1. I am the authorized driver of a motor vehicle more particularly described as follows:

Make: HYUNDAI
Series: SVX MT
Type: SUV
Engine No: D4BH4971776
Plate No.: FFL 477
Registered Owner: HELEN U. CHUANG

2. On May 22, 2020 at around 7:30 o’clock in the evening, I was moving out of our
parking lot and was not able to notice a steel post as it was gloomy and dark at that
time;

3. As a result of the said incident, the vehicle sustained damage, dents and scratches on
its Left Side Front Bumper;

4. I am executing this affidavit to attest to the truth of the foregoing facts for the
purpose of our insurance claim and for whatever purpose it may duly serve.

5. IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of

May, 2020, in Iloilo City, Philippines.

MYLES ADAM U. CHUANG

Affiant

SUBSCRIBED AND SWORN to before me this _______ day of May, 2020 in

the City of Iloilo, Philippines, affiant exhibiting to me his Driver’s License FO3-15-
008875 as competent evidence of his identity.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2020.