AFFIDAVIT OF SELF DAMAGE

I, FREDRICH IRVIN K. LOPEZ., of legal age, Filipino, Single, with office

address at the City Administrator’s Office, Tanjay City, Negros Oriental under oath,
hereby state that:

1. On May 3, 2023, I was the designated driver of a motor vehicle, particularly:

MAKE: STRADA ATHLETE 2.4D 4WD A

ENGINE NO.: 4N15UHB6649
CHASSIS NO.: MMBJLKL10MH022333

2. I was present on a convoy with the Mayor, Jose T. Orlino, on our way back
from a wedding he conducted at Barangay Pal-ew, Tanjay City. We took a shorter
route passing Barangay 1, Sitio Bogo Village, Tanjay City.

3. At approximately 3:30PM, during the course of the convoy, an unexpected

event occurred. The convoy made a sudden U-turn in an attempt to avoid an obstacle
on the road. In the process of executing the U-turn, the vehicle I was in collided with
a stump of a coconut tree, resulting in damage to the vehicle.

3. Because of the said incident, the front bumper assembly of the aforesaid
vehicle was damaged and need to be repaired and/or replaced.

4. That I am executing this affidavit voluntarily and without any mental

reservation to attest to the truth and veracity of the above-statements, and to support
my claim for insurance coverage for the damages in the said motor vehicle.

IN WITNESS WHEREOF, I hereunto set my hand this _________________ in

Tanjay City, Philippines.

FREDRICH IRVIN K. LOPEZ

Affiant
Driver’s Licence No. G08-22-000191, valid until 02/25/2026

SUBSCRIBED AND SWORN to before me this ______________ in Tanjay City,

Philippines.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2023.