Republic of the Philippines ) S.S.

Las Pinas City, Metro Manila )

AFFIDAVIT OF DAMAGE TO VEHICLE

I, xxxx of legal age, Filipino, married and with residence address at Bacoor City,
Cavite, after being sworn to in accordance with law, depose and state:

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

_____________________ which is valid until _________________________;

2. That on 15 December 2016, at around 8:00 P.M., I parked my vehicle along

__(name of street)______St., Brgy. Jaen, Nueva Ecija, which vehicle is owned
and registered in my name and more particularly described as follows:

Make :
Year :
Color :
Conduction Sticker : ________

3. After I parked my vehicle along the highway, I went to the house of a friend
located across the street and at end of an alley. At around 11:00 P.M., I went
back to my vehicle where it was parked and to my shock and disbelief, I
discovered that the left side of the vehicle was apparently bumped / hit by
another vehicle. As a result, the said left side of the vehicle was damaged;

4. I did not see any other vehicle or driver within the area who might have
bumped or hit my vehicle and would acknowledge liability, therefore, it
appeared to be a case of “hit and run”;

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 my vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this

_______________________ in Las Pinas City, Metro Manila, Philippines.
 xxxxxxxxxxxxxxxxxxxxx
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this

_________________________ in Las Pinas City, who presented his his Driver’s
License No. bkipb13253647.

Doc. No. ___

Page No. ___
Book No. ___
Series of 2017.