Republic of the Philippines )

City of Dipolog ) S.S.

AFFIDAVIT OF DAMAGE TO VEHICLE

I, MIKHAEL ELIC MAH, Filipino, of legal age, single, and a resident of South Mapang,
Rizal, Zamboanga del Norte, after being duly sworn to in accordance with law, hereby depose
and state:

1. That I am a duly licensed driver with Driver’s License Number JO107001741 which is
valid until September 11, 2022;

2. That on December 29, 2019, at around 11:00 o’clock in the evening, I was driving a
vehicle, owned and registered in the name of KATHERINE MAE ELIC MAH which is
more particularly described as follows:

Make: ISUZU Engine No: 4JJ1RM7856

Series: MUX 4X2 LS-A ChassisNo:MPAUCR85GHT00546
Body Type: WAGON Conduction Sticker No: DOC727
MV File No: 1301-00000988588

3. That while I was driving at an average speed from Dipolog City, going home to Rizal,
somewhere in Barcelona, Dapitan City, with no streetlights and signages of caution
for road construction, the vehicle fell off the road while trying to avoid an incoming
bus who did an overtake.

4. That after the vehicle swerved off the road, I discovered that the tie rod was bent, the
whole pannel bumper was scratched and broken, there were dents on the right front
side fender flare and the tire at the back rightmost part exploded;

5. That there were no traffic enforcers 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 damages caused to the
aforementioned vehicle.

IN WITNESS THEREOF, I have hereunto set my hand this 31st day of December,
2019, at Dipolog City, Philippines.

MIKHAEL ELIC MAH

Affiant
Driver’s License No. JO107001741
Valid until 09-11-2022

SUBSCRIBED, SIGNED, AND SWORN TO in my personal presence, this 31st

day of December, 2019 at Dipolog City, Philippines, affiant identified through his
competent proof of identity, the particulars of which are above-mentioned, which bear his
photograph and signature, and who avowed under penalty of law to the whole truth of the
contents of the instrument or document, which he executed freely and voluntarily.

Doc No. ______; NIZZA P. LESTERIO, CPA

Page No._____; Notary Public until 31 Dec. 2019
Book No. ______; PTR OR No. 6817075; 02-22-201
Series of 2019. IBP OR No. 076086; 03-08-2019
Roll of Attorneys No. 64993
MCLE VI 0005482;Valid until 4/14/2022
SN:ZDN DPL 030-2018