REPUBLIC 

OF THE PHILIPPINES)
CITY OF ___________________ ) S.S.
x---------------------------------------x

  
AFFIDAVIT OF DAMAGE TO PROPERTY

  I, ___________________________, of legal age, Filipino, single and a resident of

____________________________________________, after having been duly sworn to in
accordance with law, hereby depose and states:

1. That I am a duly licensed driver with Driver's License No._____________, which

is valid until ___________________.

2. That at around 12:00 P.M. of March 12, 2020, I drove a motor vehicle owned and
registered in the name of _____________________ which is more particularly described as
follows:

Make: Engine No.:

Series: Chassis No.:

Body Type: Plate No.:

Year Model: MV File No.:

3. That when I executed a reverse maneuver at the parking area of my workplace at

_________________________________________________ I accidentally bumped the rear left
side portion of a motor vehicle owned and registered in the name of
____________________________ which is more particularly described as follows:

Make: Engine No.:

Series: Chassis No.:

Body Type: Plate No.:

Year Model: MV File No.:

3. That I immediately alighted from the said vehicle to check the extent of the
damage. That upon verification, the accidental bump resulted to a damage at the rear left side
portion of the latter mentioned vehicle;

4. That at the time of the incident, I had no occasion to report to a traffic enforcer in
view of the fact that I had an urgent meeting;
 
5. That I executed this affidavit to attest to the truthfulness of the foregoing facts and
circumstances to support my insurance claim for property damage and for whatever legal
purpose it may serve.
IN WITNESS WHEREOF, I hereby affixed
my signature this ___________________ in the _____________________, Philippines.
 Affiant
I.D. No._______________

 SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant exhibiting to me his/her competent evidence of identity
by way of _________________ issued at ______________ on __________________.

Doc. No. _____;

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