Republic of the Philippines]

City of Legazpi ] s.s.

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AFFIDAVIT OF INSURANCE
I, NAT JULIAN S. BELZA of legal age, Filipino, married, a resident of #34 Blk. 40, Imperial
Rosmont Heights, Brgy. 55 Estanza Legazpi City, after having been duly sworn to in accordance
with law, do hereby depose and states that:

1. That I am the duly registered owner of Suzuki Swift with Temporary Plate No. ACR
4796 which is more particularly described as follows:

Make: Suzuki Engine No.: K12MN1765844

Series: Swift 1.2 MT Chassis No.: MA3ZC62S4HAA86581
Body Type: HATCHBACK Plate No.: ACR 4796
Year Model: 2016 MV File No.: 0501-00000048929

2. That on June 23, 2016, at around 9:00 oclock in the evening, while I was parking at
the parking lot of Embarcadero Legazpi I accidentally bump into a protruded canal
cover which causes deformity and tearing on the side skirt panel of the said car.
3. That I am executing this Affidavit to attest to the truth of the foregoing statement
and in purposes of insurance claim.

IN WITNESS WHEREOF, I have hereunto set my hand this 29th day of June 2017 at
Legazpi City, Philippines.

NAT JULIAN S. BELIZA

Affiant
UMID No. CRN-0111-5828488-7

SUBSCRIBED AND SWORN to before me this 29th day of June 2017 at Legazpi City,
Philippines, affiant exhibited himself to me his Unified Multi-Purpose Identification Card
bearing his photograph and genuine signature as competent proof of his identity pursuant to
the 2004 Rules on Notarial Practice.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2017.