REPUBLIC OF THE PHILIPPINES)

Mandaue City ) S.S.

AFFIDAVIT OF CAR DAMAGE

I, JEROME GABRIEL DE LA PENA ROXAS, of legal age, Filipino and a

resident of Poblacion, Danao City, after having been sworn to in accordance with
law, hereby depose and say:

1. That I am the manager of Nice Day Car Wash, Banilad Town Centre;

2. That Mr. James Lee P. Kintanar, the registered owner of a Black Suzuki
Jimny with plate number ACS 5955 and engine no. M13A2400436,
delivered his vehicle to Nice Day Car Wash and availed our car
washing services on February 3, 2020 at around 4 o’clock in the
afternoon;

3. That in the process of transferring his vehicle to the wash bay, I

accidentally bumped the wall thereof thereby causing damage to the
front bumper of the said vehicle, copies of the photographs of the
damaged portions are hereto attached and made an integral part of
this document;

4. That I am executing this affidavit to attest to the truth and veracity of

the foregoing facts and for whatever legal purpose this Affidavit may
serve;

5. Affiant further sayeth naught.

I have hereunto affixed my signature this 11 th day of February 2020, at

Mandaue City, Philippines.

JEROME GABRIEL DE LA PENA ROXAS

Affiant
ID: Driver’s License No. G01-92-147452
Valid until 2021-10-29

SUBSCRIBED AND SWORN to before me this 11th day of February 2020,

at Mandaue City, Philippines, affiant exhibiting to me his government issued ID
as stated below his name, as competent evidence of his identity.

Doc. No. 275;

Page No. 56;
Book No. VII;
Series of 2020.