AFFIDAVIT

I, ________ , Filipino citizen, of legal age, married , and a resident of Lot 16 Block 16 Lecaros St.
Woodsite 2, Bahayang Pag- Asa Imus, Cavite, after having been duly sworn in accordance with law,
hereby depose and say:

1.That, on or around 7 a.m. of December 31, 2014 we went to the basement parking of Prestige Tower
at Ortigas Jr. Road, Brggy San Antonio, Ortigas Center Pasig, to retrieve the Mitsubishi Montero (with
Conduction sticker Number ______) after an overnight parking.
2. That, we found it to have a drained battery possibly caused by its defective alarm system which we
have already reported with the Mitsubishi Dealer Company (Union Motors) prior to it but considering
the Christmas holidays we failed to come to the Service Shop right away.
3. That, we tried to jump start the engine, however due to my miscalculation and untimely pressing of
the cars brakes it crashed onto the wall causing damage to its front bumper and others.
4. That, we brought the same car to the Service Department of the Car Dealer (Union Motors) and their
Service Advisor gave us the quotation (attached herewith) for its services and repairs to be made on the
car.
5. That, I have executed this affidavit for purposes of claims for the said cars comprehensive insurance
policy.

Further Affiant sayeth none.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ......... day of ..................... , 20__
in ..................................... Philippines.

........................................................................
____________

SUBSCRIBED AND SWORN before me this........ day of ........................... 20__, by

............................................. who exhibited to me his drivers license number. ...................................
issued on ................................. at ...........................................

Notary Public

Doc. No. .........:

Page No. .........;
Book No. .........;
Series of 20__.