Republic of the Philippines )

City of Manila ) S.S

AFFIDAVIT OF DAMAGE TO VEHICLE

I, CHARISSE CATHERINE N. REYES, of legal age, Filipino, married, and a resident of

171 St. Joseph Street, Oranbo, Pasig City, 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. N01-14-004931 which is valid until
28 November 2022;

2. The vehicle is owned and registered in my name and is more particularly described as follows:

Model: 2019 Honda City

Color: Taffeta White
Plate Number: EOQ 764
Certificate Registration No.: 313040324
LTO Official Receipt: 1400022234

3. That on the morning of 24 September 2018 at around 9:35 am, I parked my vehicle at the
parking area of Harisson Plaza near the entrance to the SM Department Store;

4. That my vehicle was scheduled to be picked up by dealer Honda Manila, through their Honda
Associate, Mr. Chester D. Eroles, that same morning to be repaired in their service center;

5. That upon returning to my parked vehicle at around 10:00 am, and upon being told by
Mr. Eroles, there are visible cracks in the front windshield;

6. That there was no witness any incident which may cause the said damage to my vehicle while
it was parked; and

7. That I am executing this Affidavit to attest to the truth of the foregoing and in support of the
claim with the insurer for the repair of the damage caused to my vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of September 2018 in
Manila, Philippines.

CHARISSE CATHERINE N. REYES

SUBSCRIBED AND SWORN TO BEFORE ME this _________________ in City of Manila,

Philippine by Charisse Catherine N. Reyes who presented her Driver’s License
No. N01-14-004931, valid until 28 November 2022, issued in Manila, Philippines.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2018.