Republic of the Philippines)

Province of Negros Oriental)s.s.

Municipality of Sibulan.…)

AFFIDAVIT

THAT I, ROSENIE J. REMATA, of legal age, Filipino, married , and a resident of

barangay Magatas, Sibulan, Negros Oriental, after having been duly sworn to in
accordance with law, do hereby depose and manifest:

That last June 24, 2014, I and my husband was invited for a dinner in Tiera Alta,
Valencia, Negros Oriental and bringing along with us my MITSUBISHI, MONTERO
SPORTS, registered in my name under Certificate of Registration No. CR No.
159104750 and the same was park in their parking Lot;

That at around 7:00 o’clock in the evening of the same day, we went home in
Sibulan, Negros Oriental and on the following day while washing and cleaning the said
car, I discovered that the right side of the bumper was deface and I believed that the same
was accidentally bumped when I parked the said car in Tiera Alta the previous evening;

That this affidavit is executed freely and voluntarily just to attest the veracity and
truthfulness of my statements herein.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___day of

June 2014, at Sibulan, Negros Oriental.

ROSENIE J. REMATA
(Affiant)
CTC No. _________________
Issued on ____________, 2014
At Sibulan, Negros Oriental

OATH AND CERTIFICATION

SUBSCRIBED AND SWORN to before me, this 27 th day of June 2014, affiant
exhibited to me her Community Tax Certificate No. printed below her name above-
written. Further, I hereby certify that I have fully examined the affiant and I am
convinced that she has read and understood the contents of his affidavit and that the same
was executed freely and voluntarily.

TIRSO F. BANQUERIGO
JUDGE