REPUBLIC OF THE PHILIPPINES )

Province of xxx ) S.S.

City of xxx ) 
                                                     
AFFIDAVIT 
  
I, xxx, Filipino, of legal age, residing at xxx, after having been sworn in
accordance with law hereby depose and state:

1. That I am a duly licensed driver with Driver's License No. 12345

which is valid until xxx.

2. That on xxx, 2020, at around xxx o’clock in the morning, I was

driving a motor vehicle owned and registered in my name which is
more particularly described as follows:

Make: xxx Engine No.: xxx

Series: xxx Chassis No.: xxx
Body Type: xxx Plate No.: xxx
Year Model: 20xx MV File No.: xxx

3. That while I was carefully negotiating a narrow street with wire

fences on both sides, the aforementioned vehicle suddenly swept
on the protruding wire fence and as a result, the said vehicle
sustained several deep scratches at the middle portion of its left
side;

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 vehicle

IN WITNESS WHEREOF, I have hereunto set my hand this

_______________ in ___________________, Philippines.

xxx

 
          SUBSCRIBED AND SWORN to before me, this
__________________________, in ___________________, with affiant exhibiting his
Driver’s License No. 12345
 

Doc. No. __________;

Page No. __________;
Book No. __________;
Series of 20xx.