REPUBLIC OF THE PHILIPPINES )

_______________________________ ) S.S.

AFFIDAVIT

I, John Dalton Rosales, Filipino, of legal age and residing at Tower I Grass
Residences, Quezon City, after being sworn into in accordance with law, hereby
depose and state the following:

1. That I am the registered owner of Honda Civic (2016) with plate no.:
NAL3749 as evidenced by C.R. No.: 288712896, a copy of which is
attached hereto as Annex “A”;

2. That the said car was parked at the Tower I Grass Residence Parking
in a good manner without any sign of damage and when I was about
to ride my car, I saw that my bumper was broken;

3. That I requested for a CCTV footage from the Administration of

Grass Residence and and saw that it was hit/bumped by a Mitsubishi
Montero with Plate No: RDC47 when he was about to park. This is
verified and confirmed by the testimony of a Security Guard on duty
as he witnessed the same;

4. That I do hereby attest that my car has no car insurance but only Third
Person Liability Insurance, as required by law, hence I cannot request
and submit Certificate of No Claim from any Car Insurance Company;

5. In addition thereto, in case I have existing car insurance, I do hereby

attest that I will no longer claim from them;

6. That I am executing this Affidavit to attest to the truth of the

foregoing and as a substitute for Certificate of No Claim from any
insurance company.

IN WITNESS WHEREOF, I have hereunto set my hands this

_____________ at ________________.

John Dalton Rosales

Affiant

SUBSCRIBED AND SWORN to before me this ___________________

2023 in _______________________, the affiant exhibiting to me his
___________________ issued at ___________________, issued on/ valid until
_____________________, as competent proof of her identity under the prevailing
Rules on Notarial Practice.

Doc No.______
Page No._____
Book No._____
Series of 2023.