Republic of the Philippines)

Province of Batangas) S.S.

Municipality of Taysan)
x-------------------x

AFFIDAVIT

I, Mary Rose Camille E. Ebreo, Filipino, of legal age, single, and a resident
of San Isidro, Taysan, Batangas, Philippines, after being sworn to in accordance
with law, hereby depose and state:

1.That I am a duly licensed driver with Driver's License No._____________covered

by DLR No.___________, which is valid until___________.

2. That on June 14, 2019, at around 5:40 in the afternoon, I was driving a motor
vehicle owned and registered in my name which is more particularly described as
follows:

Make ____________ Motor No.:____________

Series:____________ Chassis No.:___________
Body Type:___________ Plate No.:_____________
Year Model:___________ MVRR No.:____________

3. That while I was slowly backing from the garage to the driveway, and due to
the slippery road caused by heavy rains, the tire accidentally slid causing the right-
side mirror to hit the garage post.

4. That said accident caused the following damages:

5. That I am executing this Affidavit to attest to the truth of the foregoing 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 ___ day of

________ 2019, at the province of Batangas.

_________________
AFFIANT

SUBSCRIBED AND SWORN to before me this ____ day of _______ 2019, affiant
exhibited to me a competent proof of her identity.
Gov’t issued ID Valid until
___________________ _____________________ _______________