Republic of the Philippines )

Province of Cebu ) S.S.

City/Municipality of___________ )
x-------------------------x

AFFIDAVIT

I, KATHY REYNA QUIÑ O of legal age, Filipino, married and a resident of South
Poblacion, San Fernando, Cebu, Philippines, after being sworn in accordance with law,
depose and state:

1. That sometime on 16th of February 2020 at around 5:00 in the afternoon while I
and my husband was riding a motorcycle, travelling north bound direction in the
national highway of Barangay Panadtaran, San Fernando, Cebu, a certain
Christian Mark Mamac Benaso, 33 years old, male miscalculated his distance and
bumped unto us;

2. That I was brought to Carcar District Hospital for proper medical treatment by
reason of the said accident;

3. That my personal properties such as cellphone and watch was also damaged
during the incident;

4. That by reason of such accident I together with my husband incurred and

suffered damages estimated as follows:

Cellphone repair Php. 4, 301.00

Watch repair Php. 4, 850.00
Medical Expenses Php. 1, 485.00
Motorcycle repair Php. 19, 570.00

5. That I am executing this Affidavit to attest to the truth of the foregoing and in

support of my claim for damages against Christian Mark Mamac Benaso who
caused the said injury and damages to us.

IN WITNESS WHEREOF, I have hereunto set my hand this____________at the

City of____________, Philippines.

KATHY REYNA QUIÑ O

Affiant
ID NO. PRC ID NO. 0826410
Valid until 02/18/2023

SUBSCRIBED AND SWORN to before me, this __________________ at _______________, affiant

exhibited to me her competent evidence of identity stated under her name.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2020.