REPUBLIC OF THE PHILIPPINES )

CITY OF SAN PEDRO ) S.S.

PROVINCE OF LAGUNA )

AFFIDAVIT

I, CHARINA E. RAPISURA, of legal age, married and residing at B4 L38 Phase

4, Villa Olympia, San Pedro City, Laguna, under oath, hereby depose and state:

1. I am the authorized driver of ROMMEL RAPISURA, owner of Isuzu MUX with

Plate No. AJA 4132 presently insured by BPI MS.

2. On February 3, 2018, I was driving the car inside the parking lot of Festival
Mall and waiting for a vacant parking space. While I was inside the parking
lot, there was another vehicle with a Hyundai Accent with plate no. EBY 278
driven by Rodolfo E. Eneria, Jr. that counter flowed and suddenly hit my car.
As a result thereof, the vehicle of sustained damages.

3. I am executing this Affidavit to attest the existence of damage on my car

and to request the BPI MS to cover the expenses for its repair as per the
Insurance Policy.

IN WITNESS WHEREOF, affiant hereby affixes his hand this 6th day of
February 2018 in City of San Pedro, Laguna.

CHARINA E. RAPISURA
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this 6th day of February 2018 in
City of San Pedro, Laguna, affiant exhibiting his Driver’s License with No. D04-97-
113727 issued on Feb. 18, 2015.

Doc. No. ___;

Page No. ___;
Book No. ___:
Series of 2018.