Republic of the Philippines)

Province of Davao del Norte) S.S.

City of Panabo
x--------------------------------------------------x

AFFIDAVIT OF DAMAGE

I, ATTY. DEVONA H. JUMAMIL, Filipino, of legal age, single, and a resident

of Barangay San Vicente, Panabo City, Davao del Norte, Philippines, after being sworn to
in accordance with law, depose and state:

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

covered by DLR No. ___________, which is valid until ______________.
2. That on December 1, 2019, at around 11:00 in the morning, I was driving a
vehicle owned and registered in my name which is more particularly described
as follows:

Model : Hyundai Accent 1.6 GL (DSL) MT

Chassis No. : MR9347
Engine No. : D4FBGU696639
Color : Sonic Silver
Plate Number :

3. That while I was driving the said vehicle to fetch my cousin in Jose Maria
College, Buhangin, Davao City, I ran over a pile of damaged cement.
4. That as a result of the unfortunate accident, the oil pan of the Hyundai Accent
driven by me incurred damages.
5. 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, and for all legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 3rd of November 2019 in
Panabo City, Davao del Norte, Philippines.

ATTY. DEVONA H. JUMAMIL

Affiant

SUBSCRIBED AND SWORN TO before me this_______________ at

___________________________, Philippines.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2019