Republic of the Philippines)

)S.S.
)

AFFIDAVIT OF DAMAGE TO VEHICLE

I, ______________, of legal age, married, Filipino and

a resident of, Bohol, after having sworn to in accordance
with law depose and state:

1. That I am a duly licensed Professional/Non-

Professional Driver with License No. _____________ valid
until ______________;

2. That on July 2, 2021 at around 8:00 o’clock in the

evening I am driving a ________________, owned and
registered in my name which is more particularly described
as follows:

MV File No. : _________________

Plate No. : _________________
Engine No. : _________________
Chassis No. : _________________
Make/Model : _________________

3. That while I was slowly backing out at the parking

area of Genaro’s Grill located at Bacalayon, Bohol, when I
slipped and slammed the accelerator pedal, the
aforementioned vehicle suddenly hit the post of the building
and as a result the said vehicle sustained damage at its
left side mirror (a picture of the damage is hereto attach);

4. That said damage is not intentional and that I am

always exercising extra caution and due diligence;

5. That I am executing this affidavit to attest to the

foregoing truth and in support of the insurance claim.

-______________________
Affiant
License No. __________

SUBSCRIBED AND SWORN to before me this ______ day of

July, 2021 at the __________________, Philippines.