Republic of the Philippines Province of Northern Samar Municipality of Catarman

) ) S. S. )

AFFIDAVIT OF DAMAGE TO VEHICLE I, PASCUALITO DELA VEGA AMARO, of legal age, married, driver by profession and a resident of Barangay Kinaguitnan, Allen, Northern Samar, after having been duly sworn to in accordance with law, do hereby say: That I am a holder of a Professional Drivers License with License Number N26-09000256; That I am the authorized driver of a certain utility vehicle owned and registered in the name of the Provincial Government of Northern Samar and more particularly described as follows: Make: TOYOTA Model: HIACE COMMUTER MV File No: 1340-00000495582 Engine No: 2KD5819203 Chassis No: JTFJ802P705014657 Plate No: SKS 206

That on 10 March 2014, at about six (6) oclock in the morning, I drove the abovedescribed vehicle from Catarman to fetch Governor Jose L. Ong, Jr in Calbayog City; That while in Lope de Vega en route to Calbayog City, I overtook a certain truck loaded with gravel; That on the course of the said overtaking, several fragments of gravel fell on the front glass windshield of the above-described vehicle; That as a result, the glass windshield of the above-described vehicle was broken; That the accident was not reported to the police; and That I am executing this affidavit to attest to the truth of the foregoing and in support of the claim against the insurer for the repair of the damage caused to the vehicle and for whatever legal purpose this may serve. IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of ________ 2014 at Catarman, Northern Samar, Philippines.

PASCUALITO DELA VEGA AMARO Affiant SUBSCRIBED AND SWORN TO before me this _____ day of __________ 2014 in the Municipality of Catarman, Province of Northern Samar, affiant exhibiting to me his Drivers License with No. N26-09-000256 issued by LTO Catarman. .

Doc. No._____; Page No. ____; Book No.____; Series of 2014.

ATTY. ROSA LEAH L. TEPACE-ESTUDILLO Notary Public until 31 December 2014 Notarial Commission No. 14-001 Attys Roll No. 41474 / 7 May 1997 PTR No. 2597457 / 8 Jan 2014 IBP Life No. 06187