REPUBLIC OF THE PHILIPPINES )

CITY OF LAOAG ) S.S.

AFFIDAVIT

I, MARIONNE L. MONEDA, of legal age, Filipino citizen, married and resident of Brgy.
10, Laoag City, Ilocos Norte, under oath, do hereby depose and state that:

I am the registered owner of a motor vehicle. Machine copy of the Certificate of Registration
and Official Receipt are hereto attached for immediate reference;

At around 9:00 PM on 25 May 2019, there was a parked owner-type jeep in front of our gate;

At that time I turned right going inside our house, and as I turned right, I suddenly felt and
heard a sound that hit my vehicle.

After I alighted from the vehicle, I went to check what caused the same and I discovered that
the bumper of the said owner-type jeep scraped the right door panel, right rocker panel and right
wheel of my car due to the protruding stainless bumper of the owner-type jeep;

I am executing this affidavit to attest to the truth of the foregoing facts and for whatever lawful
and legal purpose it may serve.

SIGNED, this 27 May 2019 at Laoag City, Philippines.

MARIONNE L. MONEDA
Affiant

SUBSCRIBED AND SWORN TO before me this 27 May 2019 at Laoag City, Philippines,
with the affiants personally known to me.

Doc No. ___;

Page No. ___;
Book No. IV;
Series of 2019