Republic of the Philippines}

Cebu City } S.S.

AFFIDAVIT
(DAMAGE TO VEHICLE)

I, ____________, filipino, of legal age, married and a resident of

____________________, after having been sworn to in accordance with law do
hereby depose and state that:

1. I am the registered owner of a vehicle, a __________________ with LTO

Plate No. ____________________ covered by LTO CR No.
_____________________ and LTO OR No. _______________;

2. On July 9, 2017, particularly at around 9:45 in the evening thereof, I am

on the wheel of aforesaid vehicle and maneuvering inside our parking
area for exit going to the main road located at _____________________
when its right-side portion of the rear bumper accidentally hit the concrete
wall of our neighbor fence causing damage thereon;

3. The incident causing damage to the vehicle did not arise from the
negligence or reckless driving but instead one arising from pure accident;
and

4. I executed this affidavit in order to attest to the truthfulness of the

foregoing.

IN WITNESS WHEREOF, I have hereunto set my hand this 10th day of July
2017 at Cebu City, Philippines.

____________________
Affiant

SUBSCRIBE AND SWORN TO BEFORE ME this ____day of July 2017 at Cebu

City, Philippines by Affiant who exhibited to me his ID bearing the number
__________ issued by the ________________ on _____________ at
_____________________.