Republic of the Philippines )

City of Cabuyao ) S.S

AFFIDAVIT OF DAMAGE TO VEHICLE

I, Reynaldo Gayon, of legal age, Filipino, and a resident of Block 5 Lot 52 Southville Marinig, City of Cabuyao,
Laguna, Philippines, after being sworn to in accordance with law, depose and state:

1. That I am a duly licensed driver with Driver's License No. D04-84-021054 which is valid 06-23-2022.

2. That on December 20, 2018 at around 10:00 A.M., after sending my niece at Pamantasan ng Cabuyao,
I noticed that the car was already damaged. It was a G4 Mirage 2018. A visible damage to the bumper of
the car is clearly seen. The incident happened at the parking area of said institution.

The car is owned and registered in my niece's name and is more particularly described as follows:

Model: Mirage G4

Color: Virgil Gray

Plate number: DAI 9715

Certificate of Registration No.: 332898005

LTO Official Receipt: 1489139050

4. That the security guard on duty declared to having not noticed or heard any incident causing the
said damage to my vehicle while it was in the parking lot. Neither was there a CCTV recording in the area
which can determine who caused the damage, as such, I do not foreclose the possibility that it was
another vehicle who caused said damage.
5. That I am executing this Affidavit to attest to the truth of the forgoing and in support of the claim
with the insurer for the repair of the damage caused to my vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this 20th day of December 2018 in , Cabuyao City,
Laguna, Philippines.

REYNALDO GAYON

SUBSCRIBED AND SWORN TO BEFORE ME this 20th day of December, 2018 in Cabuyao City, Philippines
by Reynaldo Gayon who presented his LTO License Driver No. D04-84-021054 , valid until June 23,
2022, issued in Laguna, Philippines.

Doc. No. ___

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Series of 2015.