Republic of the Philippines )

City of Tacloban )s.s

AFFIDAVIT OF OWN DAMAGE TO VEHICLE

I, ROSARIO D. TAMODTAMOD, Filipino, of legal age, and a resident of

959 San Isidro St., Brgy. Sta. Cruz, Palo, Leyte, Philippines, after being sworn
to in accordance with law, hereby depose and state:

1. That I am a duly licensed driver with Driver's License No. H02-17-

002364 which is valid until October 12, 2021;

2. That I was driving a motor vehicle owned and registered in my name

which is more particularly described as follows:

Make: Engine No.:

CS No.: Chassis No.:

Type: Model No.:

3. That while I was parking my car into our driveway, the aforementioned
vehicle suddenly grazed or hit a hard, wooden object and as a result
sustained damage on its left, rear passenger-side and on the right rear
bumper. My left side mirror was likewise damaged when it grazed the
gate of our driveway;

4. That while driving, said vehicle likewise sustained damages due to

rocks or stones hitting said vehicle;

5. 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 my vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this __________ in

Tacloban City, Philippines.

ROSARIO D. TAMODTAMOD
Affiant

SUBSCRIBED AND SWORN TO before me this _______________ in

Tacloban City, Philippines.
ATTY. MA. CHRISTINA ERNEST U. MOLINA
Notary Public for Tacloban City
NC No. 2019-08-92, Until Dec. 31, 2020
Doc. No. ____, 0977 R. Mendiola St., Brgy. Sta Cruz, Palo,
Page No. ____, Leyte
Book No. ____, Roll No. 72489 / 06-14-19
Series of 2019. IBP No. 108822 / 01-09-2020, Leyte Chapter
PTR No. 7943734 / 01-03-19, Tac. City