Republic of the Philippines)

Quezon City ) S.S.

AFFIDAVIT

I, CARL FRANCIS MAGNE MACASPAC DIZON, of legal age, Filipino,

presently residing at 30A Bellagio Tower 2 Forbes Town Road Bonifacio Taguig
City, after having been duly sworn to in accordance with law, do hereby depose
and state that:

1. I am the authorized driver of a motor vehicle with duly license number

N01-05-006525 given by Land Transportation Office more particularly
described as follows and owned by IROCA S. CO:

Make: HYUNDAI SUV Year & Model: 2011 TUCSON

Motor No: G4KDBU477669 Serial No: KMHJU81BBU360589
Plate No: TV1708 Color:

2. Last September 9, 2019 at around 9 o’clock in the evening while I was

backing up to park the aforesaid vehicle in my parking slot in front of El
Jardin Del Presidente 2, Sgt. Esguerra Ave., South Triangle, Quezon City. I
accidentally hit the lower part of the tree plant box behind situated in
between the parking slots. Due to that incident, the vehicle suffered
damages on the rear bumper.

3. That I am executing this Affidavit to attest to the truth of the foregoing

statement for all legal intents and purposes may further serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of

____________________ at Quezon City, Philippines.

CARL FRANCIS MAGNE MACASPAC DIZON

Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this ___ day of

_______________ in Quezon City affiant exhibiting to me his Driver’s License
with license number NO 1-05-006525 as valid proof of identification.

Notary Public
Doc. No. ____;
Page No. ____;
Book No. ____;
Series of 2019.