REPUBLIC OF THE PHILIPPINES )

Province of ____
) S.S.
Municipality of ________
)
I, ______________, Filipino, of legal age, residing at _____, after having been sworn in
accordance with law hereby depose and state:
That I am the wife of ________ who is the registered owner of a certain motor
vehicle which is more particularly described as follows:
MAKE
SERIES
YEAR MODEL

: TOYOTA
PLATENO.
: FORTUNER 4X2 CHASSISNO.
: ___
ENGINE NO.
:___

:___
:____

That on _________ at around ____ oclock in the morning, a stone originating from the
street hit the rear windshield of the above-described vehicle while the same was parked at the
carport in our house;
That the said incident caused the said rear windshield to crack;
That I am executing this affidavit to attest to the truth of the foregoing and for the
purpose of claiming from the insurance policy for the damage sustained by the vehicle.
IN WITNESS WHEREOF, I have hereunto set my hand this ___________ at _______.
______
Affiant
ID. No.________________
Valid until _____________
SUBSCRIBED AND SWORN to before me, this ____________ at ________, with affiant
exhibiting her identification shown above as competent proof of identity.