Republic of the Philippines )

Cainta, Rizal ) SS.

AFFIDAVIT

I, MARLON E. MENDOZA, Filipino, of legal age, and a resident of No. 599 Gloria
Street, Marick Subdivision, Barangay Sto. Domingo, Cainta, Rizal, under oath, do
hereby depose and state, that:

I am the driver of the motor vehicle registered under the name of Crischelle
Custodio Riel, and which is herein below more particularly described as follows:

Make/Series/Body : Toyota/Hiace Commuter/Van

Year Model : 2020
Chassis No. : JTFNAFAP3L8016756
Engine No. : 1GD8596850
Plate No. : NGA3718
MV File No. : 1301-00001560570

On December 23, 2023, on or about 8:00 p.m. I am maneuvering the above-

vehicle to park at Parking Area (B1), Ayala Mall, Manila Bay, when I miscalculated the
distance which caused me to a post. Consequent thereto, the motor vehicle sustained
damages (dents/scratches) on the following parts, to wit: rear bumper, back door, back
glass, spoiler, and door handle;

The vehicle is insured at PhilBritish Insurance under Insurance Policy No. P-

JCS-1-10-000043;

This affidavit is being executed to attest to the veracity of the foregoing statement
in order to establish the aforesaid statements for purposes not contrary to law, morals,
good custom and public policy.

IN WITNESS WHEREOF I have hereunto set my hand this 15 th day of January

2024 at Cainta, Rizal.

___________________
MARLON E. MENDOZA
Affiant

SUBSCRIBED AND SWORN TO before me on the date and at the place above-
written, affiant exhibiting to me his Driver’s License No. Driver’s License No. D19-14-
005643, valid until June 12, 2027, bearing his photo and signature.

Atty. CRISPINO T. PABLO, JR.

Doc. No. 340 ; Notary Public
Commission No. 24-12/Roll No. 49638
Page No. 68 ; Valid until December 31, 2025
PTR No. 21047215/January 2, 2024/Rizal
Book XI ; IBP Life Time No. 06272/Rizal
Series of 2024. MCLE Compliance No. VII-0010698