Republic of the Philippines )

Tacloban City ) S.S.

AFFIDAVIT OF INCIDENT WITH ACKNOWLEDGMENT OF

RECEIPT OF FULL PAYMENT

I, AAA, Filipino, of legal age, married and a resident of Brgy. Iba, Basey,
Samar, after having been duly sworn to in accordance with law hereby depose
and state that:

1. I am the owner of Joy Store, a sari-sari store located at Brgy. Roxas, Basey,
Samar;

2. The said store was involved in a vehicular accident last May 4, 2018
wherein a Mitsubishi Strada owned by one BBB, Filipino, of legal age,
married and a resident of Peerless Village, Brgy. 93, Tacloban City,
wherein the said vehicle bumped into said store thereby causing damage
to the following items, to wit:

a. 2 Cartons Emperador Light;

b. 3 Glasses Escaparate;
c. 2 Cases Pepsi (1L);
d. 3 trays eggs;
e. 1 Case Pepsi (500mL);
f. 1 Carton Ginebra San Miguel;
g. 2 plastic containers premium gasoline; and
h. portions of the store;

3. As payment for the said damaged items, I received the amount of

TWENTY-TWO THOUSAND PESOS (PHP 22, 000.00) from Mr. BBB
which I hereby fully acknowledge receipt of the same; and

4. I have executed this affidavit to attest to the truth and veracity of the
foregoing statements, and for whatever other legal purposes the same may
serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 15th day

of May 2018, in the City of Tacloban, Leyte, Philippines.

AAA
Affiant

SUBSCRIBED AND SWORN TO Before me a Notary Public for and in the

City of Tacloban, Leyte, Philippines, this 15th day of May 2018, affiant personally
appearing before me exhibiting the above document, and swore before me that he
understood the contents and the allegations therein and that the same is his free
and voluntary act and deed. Witness my hand and seal.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2018