REPUBLIC OF THE PHILIPPINES)

CITY OF IMUS ) S.S.

AFFIDAVIT OF INSURANCE CLAIMS

I, SASHA GREY, of legal age, Filipino, married, and presently residing at Blk
55, Lot 66, Ibarra Homes, Tulingan, Cavite, after having been duly sworn to in
accordance with law, depose and state:

1. I am the owner of a certain registered motor vehicle, which I inherited from

my deceased father through intestate succession, with the particular
description as follows, to wit:
MAKE: Honda
BODY: Sedan
SERIES: Civic
MODEL: 1998
PLATE NO.: UTS 101
Serial/Chassis No.: US15- 2B3509
MV FILE No.: 2477- 33438
2. On 03 October 2013 at 2 oçlock in the afternoon, the said motor vehicle met
an accident.
3. This had happened while i was parking in front of a hardware store between
the two motor vehicles, at the left side was an elf van, and while at the right
was a car. At that time, I was carefully looking at the car on my right that I did
not notice the elf van in the parking area. When I made a reverse turn, i hit
the elf by my tail light and bumper
4. It is for that reason that i am executing this affidavit to file a claim for
insurance.
5. I therefore have executed this Affidavit to attest the truth I mentioned herein
and for whatever legal purposes it may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this 30th day of
January 2014 in Imus City, Cavite, Philippines.

SASHA GREY
Affiant
Philippine Passport No. 123456
valid until January 13, 2018

SUBCRIBED AND SWORN TO before me this 30th day of January 2014 in

Imus City, Cavite, Philippines, affiant exhibiting to me her competent evidence of
identity indicated below his above- stated name.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2014.