REPUBLIC OF THE PHILIPPINES)

CITY OF _______________________) S.S.

AFFIDAVIT OF DAMAGE TO VEHICLE

I, ABC, of legal age, Filipino, and a resident of ______ City, after being duly sworn, hereby
depose and state that:

1. I am a duly licensed driver with Driver’s License No. ____ valid until ___.

2. I am currently employed as a family driver of XYZ, the registered owner of a TOYOTA

CAMRY 2020 Model with plate number AAA111.

3. On the 13 June 2023 at around 8:00 P.M., I was instructed and authorized by Mr. XYZ to use
and drive the said Toyota Camry to run errands and buy medicine at Mercury Drug___ City Branch
located at _____City. As the designated parking slots were full, I was constrained to park in front of a
nearby closed establishment along MacArthur Highway, a few meters away from the said drugstore. After
buying the medicine, I drove back to Mr. XYZ’s home at _____.

4. When I arrived at the said house and parked the vehicle at the garage, I noticed that the Toyota
Camry sustained scratches all over its body, including, but not limited to, the front and rear right hand
door, rear left hand door, fenders, and bumpers. Since the area where the Camry was parked earlier was
dimly lit, I did not immediately notice these scratches. I surmised that the Camry sustained the scratches
while I left the vehicle parked while I bought the medicine at Mercury Drug store.

6. That I am executing this affidavit to attest to the truth of the foregoing and in support of the
insurance claim for the repair of the damage caused to the said vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ in ____ City.

ABC
Affiant

SUBSCRIBED AND SWORN to before me in the City of _______ this ____ by the affiant who
exhibited to me his _____ valid until ____

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2023.