REPUBLIC OF THE PHILIPPINES)

CITY OF CEBU
) S.S.
x----------------------------x

AFFIDAVIT OF LOSS

I, JURIL BROKA PATIO, of legal age, Filipino, single and a resident of Block 6 Lot
6, Miramonte Subd., Pit-os, Cebu City, after having been duly sworn to in accordance with law,
depose and state THAT :
1. I am the registered owner of Hyundai Accent described as follows :
Type :
Make :
Engine No :
2. Last September 15, 2015, at around 2:00 o clock in the afternoon, I was about to park
at the parking area of Philippine National Bank located at Banilad, Cebu City, when I
accidentally hit the rear part of a Mini Truck which causes damaged to the left side front bumper
of my Hyundai Accent ;
3. I opted not to blotter the incident since I accept full responsibility of the damage ;
4. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and
to comply the banka requirements of withdrawing my deposit.;
IN WITNESS WHEREOF, I have hereunto set my hand this 17th day of September
2015, at Cebu City, Philippines.

JURIL BROKA PATIO

Affiant

SUBCRIBED AND SWORN TO before me this 17th day of August in Cebu City, Philippines,
affiant exhibiting to me her competent evidence of identity by way of Drivers License Number
491403265250 issued at Numazu, Japan on October 20,2014.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of ______.