Republic of the Philippines) S.S.

City of ___________ )
x--------------x

AFFIDAVIT OF DAMAGE TO VEHICLE

I, JARED MABUNGA OBIAL, Filipino, of legal age, married, and the

authorized DRIVER OF MARK MABUNGA OBIAL, the owner of the subject vehicle,
with address at ___________________________________, Philippines, after being duly
sworn to in accordance with law, hereby depose and state:

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

___________________ which is valid until __________________.

2. That on the 2nd of September 2019, at around 9:30 am, I was driving the vehicle
owned and registered in the name of Mark Mabunga Obial which is more particularly
described as follows:

Make: Engine No.:

Series: Chassis No.:
Body Type: Plate No.:
MV File No.:

3. That while I was slowly driving along Narra Street, Project 3, Quezon City, I
was hit by a passenger Jeepney, which was in front of me on the same lane, because the
said jeepney made a sudden drive backward which hit the ______________ of the
vehicle. As a result, the entire _______________________ said car’s body have been
damaged;

4. That the said passenger jeepney drove away without acknowledging its
liability, therefore, a case of “hit and run” that even the plate number of the jeepney was
impossible to be ascertained;

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

6. 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

___________________________ at City of___________, Philippines.

JARED M. OBIAL
 SUBSCRIBED AND SWORN to before me, this _________________, by
JARED M. OBIAL who exhibited to me his driver’s license with license number
________________ issued at ______________, Quezon City, Philippines on
_____________ and which will expire on ____________________.

Notary Public

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of 20____.