REPUBLIC OF THE PHILIPPINES)

CITY OF OLONGAPO
) S.S.

AFFIDAVIT
I, CARLOS P. BUSTAMANTE, JR., Filipino citizen, of legal age,
married, and with postal address at No. 79 Otero Avenue, Mabayuan,
Olongapo City, after having been duly sworn in accordance with law, hereby
depose and say:
1.

2.

3.
4.

That I am the duly owner of a vehicle more particularly described as

follows:
MAKE :

HYUNDAI

SERIES:

GRAND STAREX GL

TYPE:

VAN

YEAR MODEL:

2009

CHASSIS NO.:

KMJWAH7JP9U181796

ENGINE NUMBER:

D4CB9543920

PLATE NO.:

NZQ-958

MVFILE NO.:

1384-00000259071

That on May 4, 2012, at about 9:00 oclock in the evening, I was

about to park my Starex Van at the parking lot at the Baypointe
Hospital, located at Subic Bay Freeport Zone, when I accidentally
bumped into a piece of rock about one (1) foot high;
That as a result of the said incident, the Starex Van I was driving
sustained damage at the front bumper, light and container of its
windshield washer;
That I am executing this Affidavit to attest to the truth of the
foregoing, and in support of claims against the insurer for the repair
of the damage caused to the Starex Van I was driving.

Further Affiant sayeth none.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 6th
day of June 2012, in Olongapo City, Philippines.

CARLOS P. BUSTAMANTE, JR.,

(Signature of Affiant over Printed Name)
SUBSCRIBED AND SWORN before me this 6th day of June 2012 who
exhibited to me his PRC No. 0046967 as proof of his personal identification.

Doc. No. : 311;

Page No.: 64;

Book No.:
3;
Series of 2012.