Republic of the Philippines )

Province of Leyte ) S.S.

City of Tacloban )
x------------x

AFFIDAVIT OF DAMAGE TO VEHICLE

I, ___________, Filipino, of legal age, single, and a resident of ___________and employee of

___________with office address at ___________, after being sworn to in accordance with law, depose
and state:

1.That I am a duly licensed driver with Driver's License No___________, which is valid until

___________;

2. That sometime on the third week of September, 2019 at around 11:00 o’clock in the evening, I was driving
a vehicle owned and registered in the name of ___________, which is more particularly described as
follows:

Make ___________ Engine No___________

Model: ___________ Chassis No.: ___________
Body Type : ___________ Plate No.: ___________
Year Model: ___________ Color: ___________

3. That while I was slowly traversing the National Highway by the Municipality of San Isidro going to
Catarman, Northern Samar, I suddenly fell asleep for a few seconds and the aforementioned vehicle suddenly
hit the side of a concrete cylindrical electric post and as a result the said vehicle sustained damage at the
right side of its bumper and caused something to fall to the right side of its windshield which made a tiny
crack thereon;

4. That 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 said vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this 21st day of January 2020, in Tacloban
City, Leyte, Philippines.

__________________________
___________
SUBSCRIBED AND SWORN to before me this day, ___________, in Tacloban CIty, affiant
exhibited her identification card no: ___________ (Driver’s License) bearing her name and signature and
swore to me that the above document is her free and voluntary act and deed.

Witness my hand and seal in the place and date mentioned.

Doc No._____,
Page No._____,
Book No._____,
Series of 2020.