Republic of the Philippines )

City of Zamboanga . . . . . . .) S.S.

x-------------------------------x

AFFIDAVIT OF DAMAGE TO VEHICLE

I, MARILOU C. JATICO, of legal age, married, Filipino, a resident of Lavina Drive,
Triplet, Sto. Nino, Zamboanga City after having been subscribed to an oath, hereby
depose and say THAT:
1. I am a duly licensed driver with Driver's License No. J13-18-005876 issued by the
Land Transportation Office of Zamboanga City.

2. On March 2, 2019, at around 6:00 am, my husband was driving a motor vehicle
owned and registered in my name which is more particularly described as follows:
Make: Nissan Motor No.: YD25827950T
Series: Navara 2.0L EL Chassis No.: MNTCC2O23Z0055849
Body Type: Pick-up Plate No.: O.R. No. 000000147836598
Year Model:2019 MV File No.: 0901-00000410114

3. While we are slowly driving along the highway of Tampilisan, Zamboanga del
Norte, something suddenly hit the back portion of the vehicle, as a result the right
taillight of the said vehicle sustained damages;

4. There were no traffic enforcers nor police officers at the time of the accident;

5. I am executing this Affidavit to attest to the truth of the forgoing 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 19th day of

March 2019 at Zamboanga City, Philippines.

MARILOU C. JATICO
Affiant
DRIVER’S LICENSE I.D. No. J13-18-005876:
ISSUED/VALID UNTIL: ZAMBOANGA CITY 12/13/2022

SUBSCRIBED AND SWORN to before me this 19th day of March 2019 at

Zamboanga City, Philippines. Affiant exhibited her competent evidence of identity,
her driver’s license bearing the number as above-written.

Doc No. ____; ATTY. GIOVANNI P. GUEVARA

Notary Public for Zamboanga City
Page No. ____;
Until December 31, 2019
Book No. ____; Notarial Commission No. 68-2018
Series of 2019. PTR OR NO. 1806757, 1/04/2019, Z.C.
IBP OR NO. 063794, 1/07/2019 Z.C.
Roll of Attorneys No. 70466
2nd Flr., Reyes Building, Gov. Alvarez St.
Zamboanga City