REPUBLIC OF THE PHILIPPINES )

DUMAGUETE CITY ) SS.

AFFIDAVIT OF INCIDENT AND DAMAGES

I, _____________________________, Filipino, of legal age, married/single, and a resident of

____________________________________________, after having been duly sworn in
accordance with law, hereby depose and say:

.
1. That I am the registered owner of a Mitsubishi G4 Mirage car more particularly
described as follows:

Brand : ____________________
Model : ____________________
Color: ____________________
Engine No. : ____________________
Chassis No. : ____________________
Plate No. : ____________________
Bought : ____________________

2. That at around 07:05 a.m. on November 02, 2016, I was in the passenger seat and
my sister was driving the car when we pulled out of our garage;

3. That as the car was about halfway through the garage door, the driver’s or left side
of the car hit and scraped the garage door post;

4. That upon examining the car, I saw that the impact had caused scratch/dent on the
front left side portion of my car, particularly the driver’s door;

5. That I am executing this affidavit to attest to the truth of the foregoing facts and to
support my application for insurance claims.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _______________________

in City of Dumaguete, Philippines.

_______________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for the City of Dumaguete
this 21st day of June 2016. affiant personally came and appeared with her
____________________________________________, bearing her photograph and signature,
known to me as the same person who personally signed the foregoing instrument before me and
avowed under penalty of law to the whole truth of the contents of said instrument.

NOTARY PUBLIC

Doc. No. ____

Page No.____
Book No. ____
Series of 2020