Republic of the Philippines) S.S.

City of San Fernando, Pampanga)

x--------------x
AFFIDAVIT OF DAMAGE TO VEHICLE
I, ______________________, Filipino, of legal age, single,and a resident of
_____________________________________, Philippines, after being sworn
to in accordance with law, depose and state:
1. That I am a duly licensed driver with Driver's License No.
____________covered by DLR No.___________, which is valid
until___________.
2. That on___________, at around_______, I was driving a motor vehicle
owned and registered in my name which is more particularly described as
follows:
Make:
Series:
Body Type:
Year Model:

Motor No.:
Chassis No.:
Plate No.:
MVRR No.:

3. That while I was slowly parking my car at our houses garage, the
aforementioned vehicle suddenly hit the post of the gate from where I was
entering and as a result the said vehicle sustained damage at its bumper;
4. That I am executing this Affidavit to attest to the truth of the forgoing and
in support of the claim against the insurer for the repair of the damage
caused to my vehicle.
IN WITNESS WHEREOF,I have hereunto set my hand this _________
in___________,Philippines.