Republic of the Philippines )

City of Davao City )s.s

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AFFIDAVIT OF DAMAGE TO VEHICLE

I, MICHELLE ANNE A. YNOT, of legal age, single, Filipino and a resident of B.

109 L. 25 Ph. 7 Deca Homes, Mintal, Davao City, after having been duly sworn to in
accordance with law do hereby depose and say:

1. That I am a duly licensed driver with Professional Driver's License No. LO2-
16-003239 which is valid until 2018-09-24;

2. That on 14 May 2016, at around 3:30 pm, I drove a motor vehicle

owned and registered in the name of Merian A. Ynot which is more
particularly described as follows:

Make:Toyota Engine No.: 3SZDFL2324

Series: Avanza Chassis No.: MHKM1CE3FBK001727
Body Type: Wagon Plate No.: AAG 5191

3. That I parked the motor vehicle in an uphill along Buda-Davao Road near
Seagull Mountain Resort to buy food at a store. After attending to my
purpose and intention at the area, I got back to the motor vehicle to drive
back to the resort I was staying but when I maneuvered the motor vehicle
to drive uphill the engine died.

4. Thereafter, the motor vehicle skid backwards crashing into the road railings
causing damage to the left side (driver’s side) of the motor vehicle and the
left side mirror broken;

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 damage
caused to the above-described motor vehicle.

AFFIANT SAYETH FURTHER NONE. May 17, 2016. Davao City, Philippines.

IN WITNESS WHEREOF, I hereunto set my hand and seal this May 17, 2016, Davao
City, Philippines.

MICHELLE ANNE A. YNOT

Affiant

SUBSCRIBED AND SWORN to before me this May 17, 2016, affiant personally appeared
exhibiting to me his Competent Evidence of Identity above stated.

Doc. No.
Page No.
Book
Series of 2016