Republic of the Philippines )

City of Tacloban ) S.S

AFFIDAVIT OF DAMAGE TO VEHICLE

I, _________________ , of legal age, Filipino, widow, and a resident of

__________, 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 on December 25, 2019, at around 6:00 am, after the onslaught of typhoon
Ursula on December 24, 2019, while I was at home at _______________, I noticed
that my Nissan Navara has many visible surface scratches on the rear right side as
well as a broken right tail light, at the parking area of the New Bus Terminal, Abucay,
Tacloban City, where I used to park it;
3. The said vehicle is owned and registered in my name and is more particularly
described as follows:
Model: ___________
Color: ___________
Plate number: ___________
Certificate of Registration No.: ___________
LTO Official Receipt: ___________

4. That there were no witnesses who noticed or heard any incident causing the said
damage to my vehicle, while it was in the parking lot designated for the residents of
Happyland Subdivision. Neither was there a CCTV recording in the area which can
determine who or what caused the damage, as such, although, I do not foreclose the
possibility that it was another vehicle who caused said damage I do have a strong
inkling that the damage was due to several falling and flying debris caused by typhoon
Ursula, which the City experienced on December 24, 2019;
5. That I am executing this Affidavit to attest to the truth of the forgoing and in
support of the claim with the insurer for the repair of the damage caused to my vehicle.
IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of January
2020 in Tacloban City, Philippines.

____________________

SUBSCRIBED AND SWORN TO BEFORE ME this ____ day of January 2020 in

Tacloban City, Philippines by ________ who presented her Driver’s License __________.

Notary Public
Doc. No. ___
Page No. ___
Book No. ___
Series of 2020.