REPUBLIC 

OF THE PHILIPPINES  )
NATIONAL CAPITAL REGION )S.S.
QUEZON CITY )
X---------------------------------------------------------------/

DRIVER’S AFFIDAVIT
 
I, , Filipino, of legal age, married, and a resident of, Quezon City, after having been duly sworn
to in accordance with law, do hereby depose and state:

That I am the driver of a motor vehicle more particularly identified as follows:

MAKE  : 
YEAR MODEL : 
SERIES : 
PLATE NO.  : 
ENGINE NO. : 
CHASSIS NO.  : 
BODY TYPE  : 

That, on the first incident, I was driving the above-mentioned vehicle at home on August
15, 2022 at around 5o’clock in the afternoon. When I was driving the vehicle to my garage,
I miscalculated the distance of the gate and my vehicle, thereby causing an accident wherein
my vehicle right-side bumped the gate of my house. I managed to brake immediately when I
heard the crashing sound;

That, on the second incident, I was driving the above-mentioned vehicle at home on
August 23, 2022 at around 6o’clock in the afternoon. When I was driving the vehicle to my
garage, I miscalculated the distance of the gate and my vehicle, thereby causing an accident
wherein my vehicle’s left-side front wheel fender bumped the gate of my house.

That the above-mentioned incidents caused the damage to my vehicle. The damaged
caused were the indentation of the left fender of the front wheel of the vehicle and the
scratches in the right doors of the vehicle;

That I am executing this affidavit to establish these facts as to the damage to the car and
in support of the claim for replacement/compensation from the insurer of the said car.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 17th day of

November, 2022, at QUEZON CITY, METRO MANILA, Philippines.

Affiant
Professional Driver’s License No. issued by LTO and valid until

SUBSCRIBED AND SWORN TO BEFORE ME this __________ day of November, 2022, in

Quezon City, Metro Manila, Philippines affiant exhibiting his competent proof of identity details
of which are written below his name.

DOC. NO. ____________

PAGE NO. ____________
BOOK NO. ___________
SERIES OF 2022.