Republic of the Philippines) S.S.

City of Quezon )
x--------------x

AFFIDAVIT OF VEHICLE DEMAGE

I, NAME, Filipino, of legal age, single, and a resident of -

____________________________________, Philippines, after being duly sworn to in
accordance with law, hereby depose and state:

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

which is valid until __________________.

2. That on _______, at around _______, _______________________________:

Make: Engine No.:

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

3. State the event.

4. follow up event

5. That I am executing this Affidavit to attest to the truth of the foregoing facts
and in support of the claim against the insurer for the repair of the damage caused to said
vehicle and for all legal purposes it may serve

IN WITNESS WHEREOF, I have hereunto set my hand this ___________ at

City of Quezon, Philippines.

_____________________
Affiant

SUBSCRIBED AND SWORN to before me this __ day of _______,____ in

Quezon City, Philippines

Doc. No. ______;

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