Republic of the Philippines)

Quezon City )S.S

AFFIDAVIT OF DAMAGE TO VEHICLE

I, JAY R. GALANG, of legal age, Filipino citizen, with postal

address at No 126K 2nd St., Kamuning, Quezon City after having, been
duly sworn to in accordance with law, depose and state, that:

1. I am a duly licensed driver with Driver's License No. N02-00-

435094 valid until 2033-05-12.

2. That I am the absolute and registered owner of the vehicle and

more particularly described as follows:

MAKE MODEL : TOYOTA VIOS 1.3 XLE CV

COLOR : BLACK
ENGINE NO. : 1NRX759789
CHASSIS NO. : PA1B18F32M4166982
MV FILE NO. : 1301-00001769692
PLATE NO. : NFG3105
Year Model : 2022
MV File No. : 1301-00001769692

3. That on January 3, 2024, at around 10:00 in the morning while I

was driving, I accidentally hit an iron that hung on the passenger
seat door of my vehicle and caused damage to the passenger side
door of the said motor vehicle.

4. I am executing this Affidavit to attest to the truth of the forgoing

and in support of the claim with the insurer for repairing the
damage caused to my vehicle.

FURTHER, I SAYETH NAUGHT.

JAY R. GALANG
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this 03rd day of

January 2024, at Quezon City, by JAY R. GALANG, who has
satisfactorily proven his competent evidence of identity through his
Driver's License No. N02-00-435094, he is the same person who
personally signed before me the foregoing Affidavit and acknowledged
that he executed the same.

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Series of 2024.