Republic of the Philippines)

Province of_________________) S.S.

City/Municipality of___________)

x------------x

A F F I D A V I T OF DAMAGE TO VEHICLE

I,LESLIAN CRISCEL A. RAMIREZ,Filipino, of legal age, single, and a resident and employee of

PHILIPPINE SEVEN CORPORATION with office address 7th flr Columbia Tower ortigas Avenue

Mandaluyong City, 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. N01-11-025786 , which is valid until MAY 5

2017.

2. That on Sept 4, at around 8:30 in the evening, I was driving a vehicle owned and registered in the name

of Philippine Seven Corporation which is more particularly described as follows:

Make : HUNDAI Motor No.:

Series: TUCSON Chassis No.:

Body Type : SUV Plate No.: ZMZ 791

Year Model: 2008 MVRR No.:

3. That while I was slowly parking my car inside our parking lot in my home at 569 M.H. del pilar street San

Rafael Rodriguez Rizal when I slipped and slammed the accelerator pedal, the aforementioned vehicle

suddenly hit the rack of metal beams at the back of the parking lot and as a result the said vehicle

sustained damage at its right rear end;

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.

LESLIAN CRISCEL A. RAMIREZ