Republic of the Philippines )

City of Cabanatuan )
x------------------x
AFFIDAVIT

I, _____________________, of legal age, single, Filipino and a

resident at ________________________, after having been duly sworn to in
accordance with law, hereby depose and say:

1. That, I am the driver of a MITSIBISHI MONTERO GLS with

Plate No. ________________, which is insured under a comprehensive
insurance policy at ________________ Inc, which is registered in my name;

2. That, on January 5, 2023, as I am about to park my

abovementioned vehicle inside our garage on the said date, A strong breeze
blew up the partial portion of our front gate and accidentally hit the lower
left side of my vehicle. I was startled and immediately put my vehicle in
reverse and accidentally hit my father’s car parked inside of our garage. The
said accident caused dents and scratches on my vehicle;

3. That, I tried to avoid the said accident and carefully parked my

car in our garage but despite my efforts the said accident caused dents and
scratches on the front left bumper area and rear right bumper area of my
vehicle;

4. That I executed this affidavit to attest to the foregoing facts.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this January __, 2023 at the City Cabanatuan.

________________________________
Affiant

SUBSCRIBED AND SWORN to before me this _______ at the City

of Cabanatuan affiant exhibiting her Driver’s License _______________

___________________
Administering Officer