Republic of the Philippines )

)
) S.c.
x-----------------------------------x

AFFIDAVIT OF DAMAGE TO VEHICLE

I, ________________, Filipino, of legal age, single, and residing at

_________________________, after having been sworn to in accordance with law,
hereby depose and state the following:

1. That I am a duly licensed driver with Driver's License No. ______________ which
is valid until __________________;

2. That on _________________, after getting out from our office in

_____________________ where I usually parked my car, I noticed that my side
mirror on the right was broken and there’s a visible surface scratches on the said
side.

3. The said vehicle is owned and registered in my name and is more particularly
described as follows:

Make:
Color:
Series:
Engine No.:
Plate number:
Certificate of Registration No.:
LTO Official Receipt:

4. That the security guard on duty declared to having not noticed or heard any
incident causing the said damage to my vehicle while it was in the parking lot.
Neither was there a CCTV recording in the area which can determine who caused
the damage, as such, I do not foreclose the possibility that it was another vehicle
who caused said damage.

5. That I am executing this Affidavit to attest to the truth of the forgoing and in support
of the claim with the insurer for the repair of the damage caused to my vehicle and
for all legal intents and purposes that this affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hand on this __th day of

__________ 2020, in the ______________________.

___________________
Affiant

SUBSCRIBED AND SWORN to before me on this ___th day of ________ 2020,

in the ___________________, the affiant exhibiting to me his Driver’s License with No.
__________________ valid until ________________.

NOTARY PUBLIC

Doc No.:____;
Page No.:___;
Series of 2020.