Republic of the Philippines

Province of Cagayan )S.S.

City of Tuguegarao )

AFFIDAVIT OF DAMAGE TO VEHICLE

I, ROMUALDO M. BIRUNG, Filipino, of legal age, single, and a resident of

Cataggaman Nuevo, Tuguegarao City, Cagayan, Philippines, after having been
sworn to in accordance with law, depose and state:

1. That I am a duly licensed driver with Professional Driver’s License No. N11-
67-004827, which is valid until February 7, 2024;

2. That on February 7, 2019, I was driving a vehicle owned and registered

under my name which is more particularly describe as follows:

Make: Toyota Engine No.: 1KD2783448

Series: HIACE GL GRANDIA Chassis No.: JTFRT13P8H8022474
Body Type: VAN Plate No.: A3X270 (Sticker)
Year Model: 2018 MV File No.: 1380-00000969989

3. That while I was slowly driving backwards to leave the parking lot at
Nathan’s Panciteria, Pengue Ruyu, Tuguegarao City, Cagayan, I
accidentally hit a protruding metal attached to the tree-guard and as a
result the said vehicle sustained damage at its right front door and
bumper;

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

Tuguegarao City, Philippines.

ROMUALDO M. BIRUNG
Affiant
Driver’s License: N11-67-004827
Issued by LTO – Tuguegarao City/
Senior Citizen ID No. 18-1521
Issued by OSCA- Tuguegarao City

SUBSCRIBED AND SWORN to before me this 8th day of February 2019, in

Tuguegarao City, Cagayan, affiant exhibited to me her identifying documents stated
above which is competent evidence of identity in accordance with the 2004 Rules of
Notarial Practice.

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Series of 2019