REPUBLIC OF THE PHILIPPINES )

Province of Cavite                            ) S.S.

AFFIDAVIT OF VEHICLE DAMAGE

I, _______________________, of legal age, married, and with address
at____________________after being duly sworn to in accordance with law, hereby
depose and state:

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

_____________with expiration date on __________.

2. THAT I am authorized to drive our family car registered under the name of
my wife, _______________________, more particularly described as
follows:

Make : Engine No. :

Series : Chassis No. :
Body Type : Plate No. :
Year Model : MV File No :

3. THAT  on June 10, 2020, at around 5:00 in the afternoon, our car was parked
at ________ under an acacia tree. When I came back to get it, there was a
branch of tree beside the car. Upon closer inspection I found out that the
windshield was smashed and damaged from the impact OF the fall of the
acacia tree branch.

4. 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 car and for all legal purposes it may serve.

IN WITNESS WHEREOF, I hereunto affix my signature this _________________

at Tagaytay City, Cavite, Philippines.

                                                                            _________________________

                                                                                         
Affiant

SUBSCRIBED AND SWORN to before me this _______________ at Tagaytay

City, Cavite , Affiant exhibiting to me her_________________ with expiration date on.

NOTARY PUBLIC
Doc No. ________;
Page No. _______ ;
Book No. _______;
Series of 2020.