REPUBLIC OF THE PHILIPPINES )

City of San Fernando, Pampanga ) S.S.

CERTIFICATE/AFFIDAVIT OF DAMAGE
I, JAVE ROLDAN MAUR, of legal age, Filipino and a resident of Victoria,
Oriental Mindoro, after having been sworn in accordance with law, depose and state:

1) That I am the Regional Head Officer of UNAHCO Inc., a juridical entity

organized in accordance with the Corporation Code of the Philippines, with
address at 17 Sheridan St, City of Mandaluyong, Metro Manila, Philippines;
2) UNAHCO Inc. is the registered owner of a motor vehicle identified as follows:

Brand : TOYOTA
Model/Year/Color : 2015 HILUX 2.5L J
Motor No. : 2KDS486495
Serial/Chassis No. : MROES12G903042571
Certificate of Registration No. : 216266035
Official Receipt No. : 720127984
Plate No. : ATA 9030
3) That on __________ (DATE), I parked the said vehicle at _____ (PLACE). I
was shocked when I discovered that the vehicle was vandalized and as a
consequence, sustained the following damages:
a. Hood;
b. Fender Right Hand and Left Hand;
c. Front Door Right hand and Left Hand;
d. Rear Door Right Hand and Left Hand;
e. Bed Side Panel Right Hand and Left Hand;
f. Tail Gate.
4) That I am executing this affidavit to attest to the truth of the foregoing, for,
and for whatever other legal purposes this affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _________ day of

_________ (MONTH AND YEAR) in ___________ (PLACE).

_________________
Affiant

SUBSCRIBED AND SWORN TO before me this __ day of _____________

(MONTH AND YEAR), affiant personally appearing and known to me to be the same
person who executed the foregoing instrument, exhibiting her .
_______________________________ (ID) issued in __________ (PLACE ON
ISSUANCE OF ID) on _____________ (DATE OF ISSUANCE)

WITNESS MY HAND AND SEAL.

Doc. No. _____

Page No. _____
Book No. _____
Series of _____

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