Republic of the Philippines )

Cabanatuan City )s.s.

Province of Nueva Ecija )
x - - - - - - - - - - - - - - - - - -x

AFFIDAVIT

I, ANNE EUGENE J. SANTOS, of legal age, widow, Filipino, and a

resident of Brgy. Sagunto, Sison, Pangasinan, after having duly sworn to, in
accordance with law, hereby states:

1. That I am the driver of a vehicle, a 2016 Ford Everest 2.2 4x2

Automatic Transmission, Titanium Ford, with plate number IMO472;

2. That on July 1, 2018 at around 10:00 o’clock in the evening, I

parked the said car at the back of the PJG Hospital facing Gen. Tinio
St., Cabanatuan City, Nueva Ecija;

3. That when I was about to board the car, I noticed that there was a
damage/dent on the rear fender and bumper on the passenger side
of the car;

4. That even after thorough investigation, I was not able to determine

what caused the said damage to my vehicle;

5. That I am executing this affidavit to attest to the truthfulness and

veracity of all the foregoing declarations for purposes of facilitating
the indemnity claim from CGIC-Corporate Guarantee & Insurance
Company/Policy No. MC-00138753.

IN TRUTH WHEREOF, I have hereunto affixed my signature this 31st

day of July 2018 hereat Cabanatuan City, Nueva Ecija.

ANNE EUGENE J. SANTOS

(Affiant)

SUBSCRIBED AND SWORN TO before me on this 31st day of July 2018

hereat Cabanatuan City, Nueva Ecija with affiant showing to me his
government issued I.D. ________________________.

ATTY. MICHAEL S. DE GUZMAN

Notary Public
Until December 31, 2019
Roll No. 62204/Nueva Ecija Chapter
IBP Lifetime Member No. 018549/O.R.
023891, 01-10-208
PTR No. CBN-10 8097 01-08-2018
Cabanatuan City
MCLE Compliance No. V-0018601 04-15 2016
CP No. 0917-122-4450/09985347342
Doc No.234
Page 48
Book 1
Series of 2018