Republic of the Philippines)S.

S
City of Davao. . . . . . . . . . .)
x----------------------------------x

AFFIDAVIT OF DAMAGE

I, XXXXX XXXXX, of legal age, single, Filipino and a resident of Davao City, after
having been sworn in accordance with law, do hereby depose and say, that:

1. I am a holder of a Professional Driver’s License with No. Lxx-xxxxxxx valid until July xx,
2022;

2. I am the authorized driver of a Red Ford Ecosport Mini SUV Vehicle which is particularly
described as follows:

a. Plate No. HOW 090

b. Engine Number: xxxxxxxxxxxxx
c. Chassis Number: xxxxxxxxxxxxxxx
d. Certificate of Registration Number: xxxxxxx dated January xx, 201X
e. Original Receipt No.: Xxxxxxxxx dated January xx, 201X

3. On June 8, 2019, my girlfriend and I went to the University to help my girlfriend with her
enrolment. I parked the Ecosport across the street slightly in front of the first entrance gate
of U;

4. When I got back to the vehicle, I noticed a dent on the edge of the hood and the right tail
light broken;

5. I tried to look around the vehicle to find the cause of the damage, but to no avail;

6. I am executing this affidavit to attest to the truth of the foregoing and for whatever legal
purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ______________ in Davao

City, Philippines.

Xxxxx xxxxxxxx
Affiant

SUBSCRIBED AND SWORN to before me this ____________________ in Davao City,

Philippines. Affiant exhibited to me his Professional Driver’s License with No. Lxx-xx-XXXXX
valid until August xx, 2022 as his competent proof of identity.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2019.