Republic of the Philippines)

City of Davao ----------------)

X ------------------------------- x

AFFIDAVIT

I, (name), of legal age, Filipino, single, and a resident of (address), after

having been duly sworn to in accordance with law, do hereby depose and
say that:

a. I am the registered owner of a (brand) car bearing plate number LGH-

534;

b. Around 10:00 pm on March 2, 2018, due to poor lighting and darkness, I

hit some low-hanging/cut wires owned by Davao Light, thereby causing
dents on the bumper;

c. On another incident sometime on March 16, 2018, I was parked along

Uyanguren St. and left my vehicle unattended. When I came back, I
noticed that the right/passenger side of the vehicle already had multiple
dents;

d. Around 6:00 pm on the 20th day of March 2018, while I was on reverse, I
bumped a low stump of wood, thereby causing a dent on the back side
of the vehicle;

e. I am executing this affidavit to attest to the truth of the foregoing facts

and for whatever legal purpose it may serve.

IN WITNESS THEREOF, I hereunto set my hands this April 19, 2018 at Calinan,
Davao City, Philippines.

(name)
Affiant

SUBSCRIBED AND SWORN to before me this April 19, 2018 at Davao City, affiant
personally appeared and exhibited to me her (Type of ID) bearing number (ID
NUM).