Republic of the Philippines) of

Batangas )s.s.
X X

AFFIDAVIT of VEHICLE DAMAGE

I, MARK IAN R. CALALO , Filipino, single, of legal age, resident of Brgy. San Juan
Malvar, Batangas, after having been sworn by law hereby depose and state that:

1. I am a duly licensed driver with Driver's License No. D14-22-300183 issued by

Land Transportation Office;

2. I am an authorized driver of a Mitsubishi Mirage; body type: G4-GLX model 2024

with Plate No. DBO 4616 and I am the owner of said vehicle;

3. Last June 25, 2024, at about 9:00 pm, I parked the said motor vehicle in parking in
the area of our barangay. I saw it not more than a day ago, I noticed that the front of
my car had a big scratch and also the left side of the passenger door had a long
scratch and I think it was caused by another vehicle or a person. The motor vehicle
has dents on the said parts;

4. I am executing this Affidavit to attest to the truth of the foregoing facts and in
support of the claim against the insurer for the repair of the damage caused to said
vehicle and for all legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 09 th of July, 2024, in Malvar,
Batangas, Philippines.

MARK IAN R. CALALO

Affiant
Issued ID: Driver’s License
ID No. D14-22-300183

SUBSCRIBED AND SWORN to before me on this 09th day of July 2024, in Malvar,
Batangas Philippines.

Doc. No. ;
Page No. ;
Book No.
; Series of 2024.