REPUBLIC OF THE PHILIPPINES)

National Capital Region ) S.S.

Municipality of Pateros )

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AFFIDAVIT OF VEHICULAR INSURANCE CLAIM

I, EDGARDO C. SALCEDO, of legal age, Filipino citizen, Field Tech Manager

of Sika Philippines, Inc. with office address at Units A-B, 888 Marcos Alvarez Avenue,
Talon, Las Pinas City, after having been duly sworn to according to law, hereby depose
and state:

1. That my employer made a contract of lease of motor vehicle with

Diamond Rent A Car for a period of three (3) years which ends on June 29, 2010. Said
vehicle is a sedan Toyota Vios, model 2007, with Plate No. ZHL 705;

2. That on June 3, 2010, I used the said vehicle on my project site visit to
Texas Instrument located at Clark Field, Pampanga. Since it was raining on the said date,
when I came across a muddy place, the wheels of the said vehicle slipped down to the
muddy site, from which I tried hard to make the vehicle came up from the mud;

3. Due to the incident the said car suffered damages such as scratches on the
right-hand quarter panel, rear and front bumper, right-hand and left-hand rear door, and
right-hand and left-hand front door; and also dents on the roof;

4. That I am executing this affidavit in order to attest to the truth of the foregoing
circumstances and for the purpose of reporting the matter for insurance claims.

IN WITNESS WHEREOF, I have hereunto set my hand this 2 nd day of July 2010
at Pateros, Metro Manila.

__________________________
EDGARDO C. SALCEDO
Affiant

SUBSCRIBED AND SWORN to before me, a Notary Public, this July 2, 2010 at
the Municipality of Pateros, Metro Manila, affiant exhibited to me his SSS No. 03-
8834072.

Doc. No.____ ;
Page No. ____;
Book No.____ ;
Series of 2010.