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REPUBLIC OF THE PHILIPPINES )

Quezon City )S.S.


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AFFIDAVIT OF CAR DAMAGE

I, MA. HANNAH T. GABATAGAT, Filipino, of legal age, and a resident of Blueridge


B, Quezon City, after having duly sworn to in accordance with law, hereby depose and
say that:

1. That I am the authorized driver, of my Aunt Evangeline E. Gabagat, the registered


owner, of Toyota Innova made motor vehicle, bearing with plate number AAA-
7062;

2. That on July 9, 2019, around 1:00 p.m. I was driving the above motor vehicle in
the parking area of Fabric Warehouse in Eastwood Libis, Quezon City, and while
parking the said motor vehicle, I did not noticed that there was a small concrete
base where a lamp post already removed, causing to bump into the said concrete
base the said motor vehicle;

3. Consequently, the above vehicle sustained a heavy dent on its front left side
bumper and the same was slightly misaligned;

4. On the other hand, the above motor vehicle also sustained number of scratches
prior to the above mentioned damage sustained, but were sustained only within
this year;

5. That I am executing this affidavit to attest to the truth of the foregoing instrument
in compliance of insurance claim and for any legal purposes and intent this may
serve;

IN WITNESS WHEREOF, I have hereunto set my hand this 13th day of August,
2019, in the Quezon City, Philippines.

MA. HANNAH T. GABATAGAT


Affiant
ID No. C07-16-008767
Expiry date: 2023/08/14
Issued at LTO

IN WITNESS WHEREOF, I have hereunto set my hand this 13th day of August,
2018, in Quezon City. Affiant exhibited to me his/her government issued ID as indicated
above as proof of his/her identity.

Doc No.______
Page No._____ NOTARY PUBLIC
Book No._____
Series of 2019.