Republic of the Philippines) S.S.

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

AFFIDAVIT OF DAMAGE TO VEHICLE

I, JESUSITO DELA PAZ SE, Filipino, of legal age, married, and with residence
address at BLK. 36 LT 16 AMPALAYA ST. TUMANA CONDO MARIKINA CITY,
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. D16-
94-108923 which is valid until 21 May 2023.

2. That on 16 November 2019, at around 2:00 pm, I was driving a vehicle,

which is more particularly described as follows:

Make: HYUNDAI Engine No.: G4LCHU757025

Series: ACCENT 1.4 GL6 Chassis No.: KMRCT41BAHU284947
Body Type: SEDAN Plate No.: ZTL177
MV File No.: 1301-00000907942 Model: 2017

3. That while I was travelling along South Expressway before reaching the ramp
of the Skyway, the right side of my car, was hit by “ISUZU Truck” causing damaged of
the right side rear fender and right side rear bumper.;

4. That the said “ISUZU Truck” drove away without acknowledging its liability,
therefore, a case of “hit and run” that even the plate number of the “ISUZU Truck”
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

December, 2019 at City of___________, Philippines.

JESUSITO DELA PAZ SE

Affiant

SUBSCRIBED AND SWORN to before me, this __ day of December, 2019, by

JESUSITO DELA PAZ SE who exhibited to me his driver’s license with license
number D16-94-108923 issued at _________________, Philippines on
__________________ and which will expire on 21 May 2023.

Notary Public

Doc. No. ______;

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

Page No. ______;

Book No. ______;

Series of 2010.