REPUBLIC OF THE PHILIPPINES)

Province of La Union) S.S.

City of San Fernando)
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AFFI DAV I T
I, SALVADOR T. SABEROLA, JR., Filipino, of legal age, married, and a
resident of Brgy. San Vicente, San Fernando City, La Union, Philippines, after being
sworn to in accordance with law, depose and state:

1. Last October 14, 2018, at around 9:00 o’clock in the evening, I was driving a
motor vehicle owned and registered in my name which is more particularly
described as follows:
Make: HONDA Engine No.: R20A59053709
Series: CRV Chassis No.: MRHRM1830HP020584
Body Type: WAGON Plate No.: ADI3696
CR No.: 259353754 MV File No.: 0101-0000280600

2. While I was slowly backing out of our garage where the above-described vehicle
was parked, the aforementioned vehicle suddenly hit the post of the garage from
where I was backing out causing an object to fell from the roof of the garage;

3. As a result the said vehicle sustained damage at its bumper, fender (driver’s side)
and a crack on the windshield (driver’s side) due to the object that fell from the
roof of the garage; and

4. 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 October 15, 2018 at
San Fernando City, La Union, Philippines.

SALVADOR T. SABEROLA, JR.

AFFIANT

SUBSCRIBED AND SWORN to before me, this October 15, 2018 at San
Fernando City, La Union, Philippines.