Republic of the Philippines)

City of Zamboanga )s.s.

X----------------------------------X

AFFIDAVIT OF INCIDENCE

I, MICHELLE B. DELA PAZ, of legal age, married, Filipino citizen, and a resident
of San Jose Cawa-Cawa, Zamboanga City, Philippines, after having been duly sworn in
accordance with law, hereby depose and say, that:

1. I am the registered owner of that certain motor-vehicle which is more particularly

described as follows, to wit:

MAKE : Toyota
SERIES : FORTUNER 2.4L 4
ENGINE NO. : 2GDC414578
MV FILE NO : 0701-00000754832
CERTIFICATE OF REGISTRATION NO. : 323891551
OFFICIAL RECEIPT NO. : 1536781256

2. On ____________ at around 6:30 in the evening, while said motor-vehicle was

being parked at San Isidro, Liloy, Zamboanga del Norte, a stray wood struck said
motor-vehicle causing damage to the right side of the front bumper;

3. The damage caused upon the above-described motor-vehicle was not intentional
but purely of accidental cause;

4. I make these statements under oath and in good faith in order to establish the
fact that the damage caused was not intentional but purely of accidental cause;

5. I execute this Affidavit voluntarily to attest to the truth of the foregoing facts
based on personal knowledge and authentic records for purposes of Insurance
claim and other legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand on this 26 th day of July

2021 at Zamboanga City, Philippines.

MICHELLE B. DELA PAZ

Affiant
__________________________________

SUBSCRIBED AND SWORN to before me on 26th day of July 2021 at

Zamboanga City, Philippines. Affiant exhibited to me his competent proof of identity as
written above.

Doc. No. _____

Page No. _____
Book No. _____
Series of 2021.