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Republic of the Philippines )

City of Batangas ) S. S.


I, ___________________, of legal age, and a resident of No.

_______________, Batangas City after having been sworn to in accordance with law
hereby depose and state that:

1. I am the registered owner of a ___________ car with the following details:

MV File No.
Engine No.
Chassis No.
Conduction No.
Color Red

2. On December 19, 2018 in the evening, I parked the above-mentioned vehicle in

Barangay _______________, Batangas where I attended a wedding.

3. When I came back to my car later in the evening at around 11 o’ clock, I was
surprised to see that my bumper has been hit and damaged.

4. I tried looking for the person or car who caused the damage but no person was
identified. Bystanders stated that it could have been hit by other vehicles parked
in the said parking lot.

5. I executed this statement to attest to the truth of the foregoing matters and for
all legal intent and purposes.

IN WITNESS WHEREOF, I have hereunto set my hand this _________________

at Batangas City.

Non Professional Driver’s License No.

SUBSCRIBED AND SWORN to before me this _______________________ at

Batangas City by the affiant who is personally known to me and who exhibited her
identification printed below her name and signature.

Doc No. _____

Page No. ____
Book No. ____
Series of 2018.