Republic of the Philippines) S.S.

City of MANDAUE )

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AFFIDAVIT OF DAMAGE TO VEHICLE

I, ISRAEL D. ALIN, Filipino, of legal age, married, and a resident of Briza Subd., Nangka, Consolacion, Cebu, Philippines, after being duly sworn to in accordance with law, hereby depose and state:

1. That I am a duly licensed driver with Professional Driver's License No. G06-02-067887 which is valid until 20 October 2016.

2. That on May 18, 2015, at around 3pm, in the parking area in my office located at Tipolo Square Bldg., Tipolo, Mandaue City, I parked my motor vehicle owned and registered in my name which is more particularly described as follows:

Make: SUBARU Engine No.: 1341729Series: FORESTER Chassis No.: JF1SJ5LC5EG121413Body Type: WAGON Plate No.: 7AT-178671MV File No.: 0701-00000080128

3. That while I was slowly backing out of the driveway along Tipolo Street, Tipolo, Mandaue City, to park my car at the parking area of Tipolo Square Bldg., the aforementioned vehicle was suddenly bumped by another vehicle which was moving out from the opposite side where I was backing out and as a result my vehicle sustained damage at its back bumper;

4. That the said vehicle drove away without acknowledging its liability, therefore, a case of “hit and run” that even the plate number of the vehicle was impossible to be ascertained;

5. That there were no other persons at the time of the accident;

6. 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 the said company vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of May 19, 2015 at City of Mandaue, Cebu, Philippines.

ISRAEL D. ALIN

Affiant

SUBSCRIBED AND SWORN to before me, this 19th day of May 2015, by ISRAEL D. ALIN who exhibited to me his driver’s license with license number G06-02-067887 issued at East Avenue, Quezon City, Philippines on November 11, 2015 and which will expire on October 20, 2016.

Notary Public

Doc. No. ______;Page No. ______;Book No. ______;Series of 2015.