Republic of the Philippines )

City of Davao City )s.s

x - - - - - - - - - - - - - - - - - -x

AFFIDAVIT OF DAMAGE TO VEHICLE

I, <NAME OF DRIVER> , of legal age, single, Filipino and a resident of

<ADDRESS>, after having been duly sworn to in accordance with law do hereby depose
and say:

1. That I am a duly licensed driver with Professional Driver's License No.

_________ which is valid until __________;

2. That on <DATE>, at around <TIME>, I drove a motor vehicle

owned and registered in the name of <OWNER NAME> which is more
particularly described as follows:

Make: BRAND Engine No.: 

Series: MODEL Chassis No.: 
Body Type: Plate No.:

3. That I parked the motor vehicle in an open parking lot in __________ to

buy food at a store. After attending to my purpose and intention at the
area, I got back to the motor vehicle to drive back home but when I
maneuvered the motor vehicle to drive uphill, I pressed the pedal a bit too
much and hit a cement electric post.

OR

That I parked the motor vehicle in an open parking lot in __________ to

buy food at a store. After attending to my purpose and intention at the
area, I got back to the motor vehicle to drive back home. I have arrived
seeing the vehicle already has a damaged bumper (as seen on the photos
attached). I have inquired to the roving guard and was told that he did
not witness the accident nor there was any CCTV in the area.

4. The damage cause was <DAMAGE specification for example: to the left
side (driver’s side) of the motor vehicle and the left side mirror broken>;

5. That there were no traffic enforcers at the time of the accident;

6. That I am executing this Affidavit to attest to the truth of the foregoing

and in support of the claim against the insurer for the repair of the
damage caused to the above-described motor vehicle.

AFFIANT SAYETH FURTHER NONE. May 17, 2016. Davao City, Philippines.

IN WITNESS WHEREOF, I hereunto set my hand and seal this May 17, 2016, Davao
City, Philippines.

<NAME AND SIGNATURE>

Affiant
 SUBSCRIBED AND SWORN to before me this May 17, 2016, affiant personally appeared
exhibiting to me his Competent Evidence of Identity above stated.

Doc. No.
Page No.
Book
Series of 2016