Republic of the Philippines)

Province of _________________) S.S.

City/Municipality of ___________)
x------------x
 
AFFIDAVIT OF DAMAGE TO VEHICLE

        I, ____________, Filipino, of legal age, (single/married/widow), and a resident of __________,

Philippines, 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 ___________, at around _______, I was driving a motor vehicle owned and registered in
my name, which is more particularly described as follows:
        Make: ____________ Motor No.: ____________
        Series: __________ Chassis No.: ___________
        Body Type: ___________ Plate No.: _____________
        Year Model: ___________ MVRR No.: ____________
        3. [State the facts of the incident.]
        4. [State the damage incurred by your vehicle or any third-party property.]
        5. [State any witness present, or absence thereof, during the incident.]
        6. That I am executing this Affidavit to attest to the truth of the foregoing and in support of the claim
with the insurer for the repair of the damage caused to my vehicle.
         IN WITNESS WHEREOF, I hereunto affixed my signature this ___th day of ____________ at
____________, Philippines.
 __________________
Affiant
 
        SUBSCRIBED AND SWORN TO BEFORE ME this _____th day of __________ in __________,
Philippines by ____________ who presented his/her _________ ID No. ___________, valid until
______________, issued in _____________, Philippines.
 
Doc. No. ___
Page No. ___
Book No. ___
Series of ___