Republic of the Philippines) City of Iriga ) x----------------- x A F F I D A V I T I, Maria M.

Akiling, Filipino, of legal age, married and a resident of Lot 8 Block 8 Citihomes Subdivision, San Nicolas, Iriga 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.MC7-10-001234 which is valid until October 10, 2016 2. That on December 18, 2013, at around 12 noon, I was driving a motor vehicle owned and registered in my name which is more particularly described as follows: Make: Toyota Model: HILUX 3.0 AT Chassis No. : MBCNJP77AB012 Engine No.: 4A49JPNM9876 Plate No.: MCN765 Year Model: 2007 3. That while I was driving along Daang Maharlika, Anayan, Pili, Camarines Sur toward Downtown Pili, a UV Express Van driven by a certain Mr. Juan dela Cruz of Bagumbayan, Goa, Camarines Sur, with Plate Number ESV555, coming from Fuentebella Highway on a fast speed, bumped the right side of my vehicle causing damage to its right door inside and out, dent the right side of the hood, busted the right headlight and broke off the windshield. 4. That I sustained a head contusion and minor body injuries which forced me to undergo medical treatment and three (3) days hospital confinement. 5. That I am executing this Affidavit to attest to the truth of the forgoing and in support of the claim against the Driver and Owner of the said UV Express Van for the repair of the damage caused to my vehicle amounting to P 85,000.00, for my medical treatment amounting to P 5,000.00, and for my 3-day lost income (P 1,000.00 per day) due to hospitalization which amounts to P 3,000.00 IN WITNESS WHEREOF, I have hereunto set my hand this 21st day of December, 2013 in Naga City, Philippines.

MARIA M. AKILING Affiant SUBSCRIBED AND SWORN to before me this 21st day of _______ at _______________. I HEREBY CERTIFY that I have personally examined the herein offended party and I am satisfied that they voluntarily executed and understood their given affidavit.

Doc. No.________ Page No.________ Book No. _______ Series of ________

ATTY. MAYUMI PO Notary Public