REPUBLIC OF THE PHILIPPINES)

LA TRINIDAD, BENGUET ) S.S.

AFFIDAVIT OF DAMAGE

I, ________, of legal age, Filipino, and a resident of __________, Baguio City, Philippines, after
being duly sworn in accordance with the law, hereby depose and state that:

1. I am the authorized driver of a Motor Vehicle, which is particularly described as

follows:

Make Model:
Plate No
Model year:
Motor/Engine No.:
Chassis No.

2. On January 23, 2022 at about 9 in the evening, I parked the said vehicle at Hilltop-
Kayang Street which was fronting the Old Hilltop-Kayang Barangay Hall. When I
came back to the said vehicle at around 9:30 in the evening, I noticed that the said
vehicle suffered damages to the front part. It seemed like a car was backing or
parking and hit the front portion of the vehicle;

3. Due to the said accident, the said car incurred the following damage:

(1) Dents on the front bumper cover

(2) Damaged radiator grille
(3) Broken RH and LH headlamps

4. I am executing this Affidavit to attest to the truth of the foregoing statements for all
legal purposes it may serve.

IN WITNESS WHEREOF, I hereunto set my hand this 2nd day of February 2022
in La Trinidad, Benguet.

Affiant

SUBSCRIBED AND SWORN TO before me this 2nd day of February 2022 in La

Trinidad, Benguet. Affiant exhibited to me his competent evidence of identity with
___________________ and bearing his name and signature.