REPUBLIC OF THE PHILIPPINES )

CITY OF CAGAYAN DE ORO ……) S.S.

DRIVER'S AFFIDAVIT

I, FERNANDO R. ADRIANO, of legal age, Filipino, married and a resident

of B37, Lot 84, Phase 4, Xavier Estate, Cagayan de Oro City, after having been
duly sworn to in accordance with law do hereby depose and say:

1. That I am the registered owner of One (1) unit Mitsubishi Mirage

G4GLXI model 2014 bearing plate number 1036-AF 644 temp.;

2. That last May 30, 2014 at around 9:30 in the morning while I was
driving said Mitsubishi going home at near SM Lumbia, a flying stone
hit my driven vehicle resulting to the damage of the front windshield
lower the driver side;

3. That I considered the said incident as purely accidental.

4. That this affidavit is executed to attest to the truth of the foregoing facts
and for whatever legal purpose this may served.

IN WITNESS HEREOF, I have hereunto affixed my signature this

________ at Cagayan de Oro City, Philippines.

FERNANDO R. ADRIANO
Affiant
DL No. Prof. NO6-81-013288
Expiry date 8-20-2015

SUBSCRIBED AND SWORN to before me this __________ at Cagayan

de Oro City, Philippines.

Doc. No. ______;

Page No. ______; NOTARY PUBLIC
Book No. ______;
Series of 2014.