REPUBLIC OF THE PHILIPPINES)

REPUBLIC OF THE PHILIPPINES)CITY OF BATANGAS )S.S.

AFFIDAVIT I, JOEL EBORA, of legal age, single, Filipino citizen and a resident of Jose P. Caedo, Sr. St., Brgy 1, Batangas City, after having been duly sworn in accordance with law hereby depose and state that:

1. I am the owner of a motor vehicle covered by Certificate of Registration No. 12034519-0 dated July 7, 2011 and more particularly described as follows:

Official Receipt:626355586Date:03/15/2012MV File No. :1366-00000163296Plate No.:TIN 755Engine No.:G4FABU745881Chassis No.:KMHCT41CACU183467Denomination:Car LightMake:HyundaiSeries:Accent CVVT 1.4Body Type:SedanYear Model:2012

2. On July 9, 2015, at about 3:00 o'clock in the afternoon, as I was parking the above-described motor vehicle at our parking area, unknowingly and purely due to miscalculation of the said area, the car hit a nearby post;

3. When I inspected the said vehicle, I saw that it suffered dents and scratches on the front part of the vehicle specifically the following parts: a.Front Bumper Coverb.Front Bumper Bracket RHc.Front Bumper Clipsd.RH Fender Panele.FRT Bumper Cover

4. The above subject vehicle is covered by an insurance policy of Commonwealth Insurance with Policy No. 1108444 covering the period from 12:00 PM of April 2015 to 12:00 PM of April 2016 ;5. I am executing this Affidavit to attest to the truth of the foregoing and for the purpose of informing the insurer of the occurrence of the above incident and further for whatever legal intent or purpose it may serve.

FURTHER AFFIANT SAYETH NAUGHT.

JOEL EBORA Affiant

SUBSCRIBED AND SWORN to before me this 6th day of March, 2015 in Batangas City, personally appeared RENIEL G. SUAREZ who exhibited to me his Drivers License with number D01-08-011617.

Doc. No. 191;Page No. 40; Book No. I I I; Series of 2015.\\STORAGE\Volume_1\all data\_MLM\LEGAL FORMS\AFFIDAVITS\CLAIM FOR INSURANCE.Reniel Suarez