Republic of the Philippines )

Province of Davao del Norte )S.S

City of Panabo )
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AFFIDAVIT OF OWN DAMAGE

I, _____________, Filipino, of legal age, married and a resident of Barangay New Visayas,
Panabo City, Davao del Norte, Philippines, after having been sworn in accordance with law do
hereby depose and state that:

1. I am a co-owner and the authorized driver of a motor vehicle, registered to my spouse,

_______________ with Certificate of Registration No. ___________ and particularly
described as follows:

Make and Series: Ford Ranger DBL 2.2L

Body Type: Pick-up
MV File No.:
Plate No.:
Engine No.:
Chassis No.:

2. On October 20, 2018, at around 10:30 in the evening, I was driving my above-mentioned
vehicle from Tagum City going to my residential house in Panabo City. While traversing
the national highway in Tagum City, I accidentally bumped a DPWH (barandilla) made
out of kawayan which was fully covered with mud which caused damaged in the left
portion of the headlight/fog lamp and including the bumper area;

The incident imbalanced my driving attention that I had to immediately manage the
steering wheel to the right without noticing a stock pile of round concrete culvert and as
a result, bumped the right side of the front bumper of my driven vehicle. I slowly reversed
and turn to the right path and drove away, however I noticed that the sound of the horn
has changed, and the diesel meter counter display was busted and as such had displayed
incorrect counters.

3. I hereby execute this affidavit to apprise the concerned insurance company for the damage
I caused by my own volition and oversight, to attest to the truth of the foregoing and for
whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto affix my signature this ____________ at

Panabo City, Davao del Norte, Philippines.

______________________
Affiant
Valid ID No. ___

SUBSCRIBED AND SWORN to before me this ___________ at Panabo City, Davao del
Norte, Philippines. Affiant exhibiting to me her IBP Identification Card as proof of her identity.

Doc No. _____:

Page No. ____;

Affidavit of Own Damage

Book No. ____;
Series of 2018.

Affidavit of Own Damage