Republic of the Philippines )

AFFIDAVIT

I, PRINCESS IRISH PERIN MELECIA Filipino, of legal age, Blk 14 Lot 12 PH 2 Lancaster Residences,
Alapan II-A, Imus City 4103 Cavite, after having been duly sworn to an oath in accordance with law, do hereby
depose and say:

1. That I am the registered OWNER of certain vehicle described as follows:

Vehicle Type: Utility Vehicle WAGON

Color Type: SILVER METALLIC 1
File No: 040124000882985
Year Model: 2024
Plate No: DBN9154

2. That in the afternoon of February 6, 2024 while I was on my way going to my residence, driving the said
vehicle, some hard/stone objects from nowhere hit the front windshield glass of the vehicle;

3. That due to said impact, the vehicle’s front windshield glass were broken and damaged;

3. That I am executing this affidavit to inform the insurance entity about such incident as one of the
requirements for insurance claim;

4. That I am executing this affidavit to attest to the truth of the foregoing facts and for all other legal intents and
purposes this may serve.

IN WITNESS WHEREOF, I have hereto set my hand this _____ day of February , 2024 in Tanza, Cavite,
Philippines.

PRINCESS IRISH PERIN MELECIA

Affiant

SUBSCRIBED AND SWORN to before me this ___ day of ____________ in _______________________,

Philippines. Affiant exhibited to me her __________________________________________________ as
competent evidence of her identity.

Doc No. _______;

Page No. _______;
Book No. ________;
Series of 2024