Republic of the Philippines)

Mandaue City-----------------)

AFFIDAVIT OF INCIDENT

I, Marian Faye M. Cuyos, of legal age, single filipino citizen and a resident at
Tapilon, Daanbantayan, Cebu, after having been sworn in accordance with hereby
depose and state that:

1. I am the authorized driver of that motor vehicle registered under the name of
my father, Ryan C. Cuyos, which vehicle is specifically described as follows:

O.R. NO. : 1727237805 issued on 9/13/2019

MAKE : TOYOTA HILUX
PLATE NO. : AED-1390
BODY TYPE : PICK-UP
ENGINE NO. : 2GD8071719
CHASSIS NO: MROG8800XG1320629

2. On September 16, 2019, at around 5:00 p.m. while I was driving along the
highway at Guadalajara, Barangay Guadalupe, Cebu City, I accidentally
sideswiped an electric post on the said highway, which I did not see from the
rearview and side mirrors;

3. The impact caused a dent and scratch on the right side of the above-described
motor vehicle, particularly damaging the back portion close to its tail light
thereof, a copy of the picture is attached as reference;

4. I am executing this affidavit to attest the truth of the foregoing circumstances,

for purposes of claiming the said motor vehicle’s insurance, and for whatever
legal purpose it may serve.

IN WITNESS HEREOF, I have hereunto set my hands this24th day of September,

2019, at Mandaue City, Philippines.

MARIAN FAYE M. CUYOS

Affiant
Driver’s License No. GO5-008382
Valid until 2023

SUBSCRIBED AND SWORN TO before me this ___ day of September, 2019, the
affiant who exhibited to me her competent evidence of her identity, that she is the same
personally appeared and signed the foregoing affidavit.

Doc No.____
Page No.___
Book No.___
Series of 2019