AFFIDAVIT

I, __________________, of legal age, married, and with residence at

____________________________________, after having been duly sworn in accordance
with law, hereby depose and state:

1. I am a licensed non-professional driver and the owner of the Toyota Avanza

motor vehicle with plate number _____________.

2. On _________________________, I was parking my vehicle inside my residence

when I miscalculated and accidentally hit the gate and posts in my garage. The
impact left a substantial dent and scratches at the ______________________.

3. I am executing this Affidavit to support my application for insurance claim.

IN WITNESS WHEREOF, I have executed this Affidavit on _______________ in

______________________.

AFFIANT
Affiant

SUBSCRIBED AND SWORN before me in _______________ this

_______________, affiant having exhibited to me her LTO Driver’s License No.
________________.

Doc No. _____;

Page No. _____;
Book No. _____;
Series of 2020.