REPUBLIC OF THE PHILIPPINES )

CITY OF ANGELES ) -s.s.

AFFIDAVIT

I, BERNA VILLASENOR DE LEON, of legal age, Filipino, single, with residence and
postal address at Blk 27, Lot 47, Fiesta Ave., Fiesta Communities, Brgy. Tabun, Angeles City,
after having been duly sworn to in accordance with law, hereby depose and say, that:

1. I am the driver and a registered owner of a motor vehicle bearing a Conduccion Sticker
with No. A9 Y339, and more particularly described as follows:

Make and Type : Toyota

Body Type. : Hiace S.G LXV
Model : 2019
Chassis No. : JYFST23P8J0038833
Engine No. : 1KD2840429

2. On the 13th of March at about 12:00 a.m., while I was maneuvering the above-mentioned
vehicle to park inside our garage, I was surprised that I hit the metal of our fence and/or gate;

3. It was a sudden movement because the sensor of my vehicle failed to detect the proximity
of the said fence;

5. When I checked the the vehicle, it was heavily damaged, specifically there are
dents and scratches in its rear door and its rear tail light was broken;

6. I am executing this affidavit to attest to the truth and veracity of the foregoing facts, and to
serve as a supporting document to the insurance claim with STANDARD INSURANCE INC.,
and for payment of the damage to said vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this 15th of March 2019 in
Angeles City, Philippines.

BERNA VILLASENOR DE LEON

Affiant

SUBSCRIBED AND SWORN to before me this 15th of March 2019 in Angeles City,
Philippines, by BERNA VILLASENOR DE LEON , who satisfactorily proven to me her identity
through her Philippine Passport with No. P7704867A and who is the same person who
personally signed before me the foregoing “Affidavit”, and acknowledged that she executed the
same.

Doc No. ___;

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