A F F I D AV I T

I, RED GABRIEL W. CONVOCAR, Filipino, single, of legal age, and with

residence at Yellow Bell St., Gran Plains Subdivision, Jaro, Iloilo City, after having been
sworn under oath, state that:

1. I am the driver of a motor vehicle registered under the name of my mother,

MARLYN W. CONVOCAR, and more particularly described as follows:

MAKE : HONDA
SERIES : CIVIC
MODEL : 2022
COLOR : WHITE
BODY : SEDAN
ENGINE NO : L15BG2785103
CHASSIS NO : MRHFE1680NP020383
PLATE NO : E3 0560 (Temporary)

2. On September 18, 2023 at around 5:35 PM, I arrived in SM City Iloilo at

Mandurriao, Iloilo City. I parked the said Honda Civic RS in the parking area at the back of
the mall. There was no car on either the left or right side of my parking space at that time;

3. Upon returning to the car at around 7:00 PM, I noticed that the left mirror of
the car was now folded. But I am sure that before I left the car in the parking lot, I did not fold
the mirrors. There was also no car on the left side of the parking space upon my return;

4. After which, I pressed the button for the mirrors to return to their original
place. Curious to see if the folding has damaged the mirror mechanism, I pressed the button
for the automatic folding of the mirrors. To my surprise, the left mirror no longer fully closes.
Instead, it only partially closes for only a few inches/ degrees. I pressed it for several times
but it had the same results.

5. On September 19, 2023, I once again tested the folding mirrors several times
but this time they folded fully but the left one seemed to fold slower than the right. The
following day, I tested it several times and the left mirror did not fold fully again.

6. On September 21, 2023, I had the car checked with Honda Cars Iloilo and they
discovered that there is something wrong with the mechanism with the left mirror and made
an estimate of the damage repairs/replacement.

7. I am executing this affidavit to attest to the truth of the foregoing and in

support of the claim for payment of insurance benefit.

IN WITNESS WHEREOF, I have hereunto set my hand this ______________, in the

City of Iloilo, Philippines.

RED GABRIEL W. CONVOCAR

Affiant

SUBSCRIBED AND SWORN to before me this _____________ in Iloilo City,

Philippines. Affiant exhibited his competent evidence of identity, viz: LTO Driver’s License
No. F03-11-001335
Doc. No. ______
Page No. ______
Book No. ______
Series of 2023.