Republic of the Philippines )

City of Zamboanga . . . . . .) S.S.

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AFFIDAVIT OF DAMAGE TO VEHICLE

I, FLORIZA D. DIOQUINO, of legal age, married, Filipino, a resident of B1 L24
Blue Homes Executive Subdivision, Pasonanca, Zamboanga City after having been
subscribed to an oath, hereby depose and say THAT:
1. I am the registered owner of a motor vehicle particularly described as follows:
Make: Toyota Motor No.: 1KD2750328
Series: HIACE Commuter Chassis No.: JTFJT02P9H5011994
Body Type: Van Plate No.: O.R. No. 000000115318393
Year Model:2018 MV File No.: 0901-00000254984

2. On April 15, 2019, at around 9:30 pm, my husband, a duly licensed driver with
Driver’s License No. N16-82-034413 was driving the said motor vehicle.

3. While we are slowly driving along the highway of Curuan, Zamboanga City, we did
not notice that one lane of the road was under construction. Hence, we bumped
on a steel pole located in the middle of the road and as a result of the accident
the said vehicle sustained the following damages:
(1) Broken left headlight; (2) dented and unaligned front hood; (3) damage to
grills and bumper and (4) leaked water reservoir for wiper.

4. There were no traffic enforcers nor police officers at the time of the accident;

5. I am executing this Affidavit to attest to the truth of the forgoing and in support
of the claim against the insurer for the repair of the damage caused to my vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this 30th day of

April 2019 at Zamboanga City, Philippines.

FLORIZA D. DIOQUINO
Affiant
PNP I.D. No. 19A150183:
ISSUED/VALID UNTIL: ZAMBOANGA CITY 12/3/2022

SUBSCRIBED AND SWORN to before me this 30th day of April 2019 at

Zamboanga City, Philippines. Affiant exhibited her competent evidence of identity,
her PNP ID bearing the number as above-written.

Doc No. 144; ATTY. GIOVANNI P. GUEVARA

Page No. 30; Notary Public for Zamboanga City
Book No. I; Until December 31, 2019
Notarial Commission No. 68-2018
Series of 2019. PTR OR NO. 1806757, 1/04/2019, Z.C.
IBP OR NO. 063794, 1/07/2019 Z.C.
Roll of Attorneys No. 70466
2nd Flr., Reyes Building, Gov. Alvarez St.
Zamboanga City