AFFIDAVIT

I, Edgardo Opulencia Filipino, of legal age, married, and a resident of

_____________, Philippines, after being sworn to in accordance with law, depose and
state:

1 That I am a duly licensed driver with Driver's License No. N0190808158 which
is valid until _____________.

That on August 31, 2017 at around 8:00 a.m1., 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 out of the driveway along _____________
Street, _____________, to park my car at the parking area of _____________, the
aforementioned vehicle suddenly hit the post of the building from where I was
backing out and as a result the said vehicle sustained damage at its
_____________;

4 That I am executing this Affidavit to attest to the truth of the forgoing 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 _____________ in

_____________, Philippines.