REPUBLIC OF THE PHILIPPINES)

________________ CITY )S.S.

AFFIDAVIT OF DAMAGE
OF MOTOR VEHICLE

I, PRECIOUS MARIE H. BAJALA, Filipino, of legal age, and with

postal address at 45 Doña Rita Diaz St., Fortunata Village, Sucat, Paranaque
City after having sworn in accordance with the law, hereby depose and
state, That - -

1. I am a duly licensed driver with Driver’s License No.

N03-08-011484, which is valid until September 21,
2013;

2. On 31 July 2012, at around _______ o’clock in the

evening, I was driving a motor vehicle owned and
registered in the name of my mother, Milagros H.
Bajala which is more particularly described as follows:

Make: Toyota Rav4 4x2

Motor No.: 1324-00000718628
Chassis No.: JTMZD31V905087861
Plate No.: ZMA-542
Year Model: 2008

3. I was parked along Aguirre Avenue. As I maneuver the

motor vehicle from being parked, I suddenly and
unexpectedly bumped into a Red Toyota Corolla;

4. With such mismaneuver and as a result thereof, the

said vehicle sustained damage at its front left bumper;

5. I am executing this Affidavit to attest to the truth of the

forgoing and in support of the claim against the insurer
for the repair of the damage caused to my vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this ____th

day of August 2012 at _____________.

PRECIOUS MARIE H. BAJALA

Affiant

SUBSCRIBED AND SWORN to before me this ____th day of

August 2012 at _______________, affiant exhibiting to me her Driver’s
License with Number N03-08-011484 as competent evidence of identity.

NOTARY PUBLIC

1
Doc. No. _____
Page No. _____
Book No. _____
Series of 2012.