(Affidavit of Damage to Vehicle Hitting a Post while Backing)

REPUBLIC OF THE PHILIPPINES)

Province of ____________________) S.S.
City/Municipality of _____________)
x-----------------------x

AFFIDAVIT

I, _____________, Filipino, of legal age, (single / married / widow), 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: _____________ Motor No.: _____________

Series: _____________ Chassis No.: _____________
Body Type: _____________ Plate No.: _____________
Year Model: _____________ MVRR No.: _____________

3. That while I was slowly backing out of the driveway along _____________ Street,
_____________, to park my car at the parking area of _____________, the
aforementioned vehicle suddenly hit the post of the building from where I was
backing out and as a result the said vehicle sustained damage at its
_____________;

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.

AFFIANT
(JURAT)