Republic of the Philippines )

City of Iloilo
) S.S
x--------------------------------x

AFFIDAVIT OF DAMAGE
I, _______________ of legal age, Filipino, widow and a resident of
____________________, after having been duly sworn in accordance with law, hereby
depose and state:
1. That I am the registered owner of a motor vehicle more particularly
described as follows:

2. That sometime last April 15, 2015, while I was backing out of our gate, I
accidentally scratched the left side of my car against the wall, which caused
damaged to the vehicle as follows:
a. Left Side Rear Bumper Cover
b. Left Side Running Board
3. I execute this affidavit to attest the truth of the foregoing facts and for the
purpose of claiming against my insurer.
IN WITNESS WHEREOF, I have hereunto set my hand this 8th day of June 2016 at
Iloilo City, Philippines.

Affiant
SUBSCRIBED AND SWORN to before me this 8th day of June 2016 at Iloilo
City, Philippines, affiant personally appeared with her competent evidence of
identity which is ____________________________.
Doc. No _____;
Page No _____;
Book No _____;
Series of 2016.