(Affidavit of Damage to Vehicle Cannibalized Vehicle)

Republic of the Philippines)

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

AF F I D AV I T

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

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

That I am the true and registered owner of a certain motor vehicle, more particularly
described as follows:

_____________
Motor No.:_____________
Chassis No.:_____________
Plate No.:_____________

That I am a duly licensed driver with Professional Driver's License

No._______________, which is valid until ______________.

That on _____________, at around_________, I parked the said motor vehicle

at____________.

That after an_____________later, when I returned to the said vehicle, I was surprised
as I arrived to find the___________of my motor vehicle stolen and my car vandalized.
There were scratches on the front right side of it, with its paintwork damaged and needs
repair.

That I am executing this Affidavit to attest to the truth of the foregoing and in support of
my claim on the insurance of the said motor vehicle.

IN WITNESS WHEREOF,I have hereunto set my hand this_____________, the City

of___________, Philippines.

AFFIANT

(JURAT)