Republic of the Philippines )

Caloocan City

)S.S.

AFFIDAVIT of VEHICLE DAMAGE

I, ______, of legal age, Filipino citizen, single, and a resident of ____,

after being sworn to in accordance with law, depose and state that:
1 I am a duly licensed driver with Driver's License No. __;
2 I am an authorized driver of a ___with Plate No. ___ which is owned
by ____;
3 Last August 6, 2015, at about 1:00 in the afternoon, I parked the said
motor vehicle outside our house at ____Caloocan City. After having
lunch at about 2:00p.m., I went to check the said vehicle. I noticed
that the rear left portion of said motor vehicle as well as the left side
of its body had been damaged. The motor vehicle has dents on the
said parts.
4 I am executing this Affidavit to attest to the truth of the foregoing
facts and in support of the claim against the insurer for the repair of
the damage caused to said vehicle and for all legal purposes it may
serve.
IN WITNESS WHEREOF, I have hereunto set my hand this 11 th
day of August, 2015 in Caloocan City, Philippines.

Affiant

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

2015 in Caloocan City, Philippines.

Doc No. : ______

Page No.:______
Book No.:______
Series of 2015.