Republic of the Philippines)

S.S.City of ___________ )

x--------------x

AFFIDAVIT OF DAMAGE TO VEHICLE

I, (FULL NAME), Filipino, of legal age, single, living at the residential address at (ADDRESS),
Philippines, after being duly sworn to in accordance with law, hereby depose and state:

1. That I am a duly licensed driver with a Non-Professional Driver's License No.

___________________________which is valid until _______.

2. That on (DATE OF ACCIDENT), at around (TIME OF ACCIDENT), I was driving my car

more particularly described as follows:
Make: _____
Series: _____
Color: _____
Body Type: ______
Plate No.: ______

3. (NARRATION OF INCIDENT)

4. That it was a hit and run. I was parked and that when I returned to my car there was
already damaged to my car.

5. (AREA OF DAMAGE)

6. That there were no traffic enforcers at the time of the accident;

7. 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 the said company
vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of December, 2018 at
City of___________, Philippines.

NAME
SUBSCRIBED AND SWORN to before me, this __ day of December 2018, by NAME who
exhibited to me his driver’s license with license number (****) which is valid until 3 April 2023

Notary Public

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of 2018