(Affidavit of Damage to Vehicle Hitting a Post while Backing)

Republic of the Philippines)

Province of_________________) S.S.
City/Municipality of___________)
x------------x

AF F I D AV I T

I,____________,Filipino, of legal age,(single / married / widow),and a resident

of__________, Philippines, after being sworn to in accordance with law, depose and
state:

1.That I am a duly licensed driver with Driver's License No._____________covered by

DLR No.___________, which is valid until___________.

2. That on___________, at around_______, I was driving a motor vehicle owned and

registered in my name which is more particularly described as follows:

Make____________ Motor No.:____________

Series:__________ Chassis No.:___________
Body Type:___________Plate No.:_____________
Year Model:___________MVRR No.:____________

3. That while I was slowly backing out of the driveway

along__________Street,____________,to park my car at the parking area
of___________, the aforementioned vehicle suddenly hit the post of the building from

where I was backing out and as a result the said vehicle sustained damage at its
__________;

4. That I am executing this Affidavit to attest to the truth of the forgoing and in support of
the claim against the insurer for the repair of the damage caused to my vehicle

IN WITNESS WHEREOF,I have hereunto set my hand

this___________in___________, Philippines.

AFFIANT

(JURAT)