Republic of the Philippines) S.S.

City of Valenzuela)

x- - - - - - - - - - - - - - - x

AFFIDAVIT

I, ______________________________, Filipino, of legal age, single, and a

resident of ______________________________, after being sworn to in accordance
with law, depose and state:

1. That I am a duly licensed driver with Driver's License No. _____________

which is valid until 15 October 2018;

2. That on 7 June 2015, at around 5:00 o’clock in the afternoon, I was driving
a vehicle owned and registered in the name of ______________________________
which is more particularly described as follows:

Make: TOYOTA Engine No.:

Series: AVANZA 1.3E A/T Chassis No.:
Body Type: WAGON Plate No.:
Year Model: 2010 MV File No.:

3. That I was slowly backing out of the parking area in our house garage
when the aforementioned vehicle suddenly hit the front gate of our house and as a
result the said vehicle sustained damage at its bumper;

4. That no other vehicle was involved; and

5. That I am executing this affidavit to attest to the truth of the foregoing and
in support of the claim against the insurer for the repair of the damage caused to the
said vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this 9 th day of June in the
City of Valenzuela, Philippines.

Affiant
 SUBSCRIBED AND SWORN to before me, this ____ day of June, 2015 in the
City of _________________, affiant exhibiting before me his
______________________________, issued at Quezon City on January 13, 2014.

NOTARY PUBLIC

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2015.