Republic of the Philippines)

Province of_________________) S.S.

City/Municipality of___________)
x - - - - - - - - - - - - x

A F F I D A V I T

I,Moheddin U. Sumagayan,Filipino, of legal age, married and

a resident of #21 Jamille Street, MCS, Brgy. San Miguel, Iligan
City, Philippines, after being sworn to in accordance with law,
depose and state:

1.That I am a duly licensed driver with Driver's License No.M05-

97-008645 covered by DLR No.___________, which is valid until 13
March 2012.

2. That on September 10, 2010, at around 12 noon, I was driving

a motor vehicle owned and registered in my name which is more
particularly described as follows:

Make: Mitsubishi Model: STRADA 3.2 GLS Sport 4x4 AT

Chassis No. : MMBJRKB80AD022 Engine No.: 4M41UCAT7221
Plate No.: PLI 671 Year Model:

3. That while I was taking Gomiza Avenue fronting Bato Mosque in

Marawi City, the aforementioned vehicle was bumped by a
motorcycle causing damage to its bumper and right fender.

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

the forgoing and in support of the claim against the insurer for
the repair of the damage caused to my vehicle

IN WITNESS WHEREOF, I have hereunto set my hand

this___________in___________, Philippines.

MOHEDDIN U. SUMAGAYAN
AFFIANT
(JURAT)