REPUBLIC OF THE PHILIPPINES )

XXXXXXXXXXXXXXXXX CITY ) S.S.

AFFIDAVIT

I, XXXXXXXXX, of legal age, Filipino, and a resident of XXXXXXXXXXX City, that after having sworn
in accordance with law, hereby and depose that:

1. I am the driver and the registered owner of a XXXXXXXXX with the following details:

Certificate of Registration No.: XXXXXXXXXX

Plate No.: XXXXXX
Chassis No.: XXXXXXXXX
Engine No.: K12XXXXXXXX
Year Model : 20XXXXXXXX
Body Type: SeXXXX

2. I am a duly licensed driver with Driver’s License No. K02XXXXXXXXXXXX issued by the Land
Transportation Office.

3. I usually park my vehicle in the parking space in our office building at XXXXXXXXXXXXXXX.

4. On 18 May 2023, at around 3:00 PM, I took out a roll of metal wire from my trunk, after closing
the trunk, I placed the wire on top of it.

5. I did not notice that the other end of the metal wire was not tied properly, hence when I took
the metal wire, the loose end scratched a portion of the trunk.

6. Due to the said accident, there is a scratch (single line) on the right portion of the trunk’s top
that needs to be repainted

7. I am executing this affidavit in order to attest to the truth of the foregoing facts, to comply with
the requirements for my uncle’s insurance claim in relation to the aforementioned damage, and
for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 29 May 2023 at XXXXXXXXXX
City, Philippines.

XXXXXXXXXXXXXXXXXXXXXXX
AFFIANT
K02-09-XXXXXXXXXXXXXX

Subscribed and sworn to before me this 29 May 2023 at XXXXXXXXXXXXX City. Affiant exhibited to
me his Driver’s License No. XXXXXXXXXXXXXXXXX

Doc. No. ____;

Page No. ____;
Book No. ______;
Series of 2023.