REPUBLIC OF THE PHILIPPINES)

City of Tacloban ) S.S.

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AFFIDAVIT

I, FRANCIS B. COSTAS, Filipino, of legal age, married, and a resident of Pob. Del
Norte, Villaba, Leyte, Philippines, after being sworn to in accordance with law, depose and
state:

1 That I am a duly licensed driver with Driver's License No. H03-10-000599 ,

which is valid until December 2, 2023;

2 That on March 17, 2021, at around 5:30pm, I parked my motor vehicle owned
and registered in my name. which is more particularly described as follows:

Make: Toyota Motor No.: 1NRX203960

Chassis No.: PA1B19F34H4043180
Plate No.: 0801-134633
Series: VIOS 1.3J GAS M
Year Model: 2018

3 That on said date, the said vehicle was parked properly at the parking area of
the Costas residence at Pob. Del Norte, Villaba, Leyte.;

4 That I forgot to engage the handbrake lever of my vehicle when I parked it;

5 That my vehicle slid from the original place where it was parked and bumped on the
pillar of the garage;

6 That I stopped to see the condition of the back portion of my vehicle;

7 That the back bumper of my vehicle suffered a crack on the right side due to
such collision;

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

IN WITNESS WHEREOF, I have hereunto set my hand this 25th day of May 2021 in
Tacloban City, Philippines.

FRANCIS B. COSTAS
AFFIANT

SUBSCRIBED AND SWORN to before me this 25th day of May 2021 in

Tacloban City, Philippines, affiant personally known to the Notary Public.