Republic of the Philippines)

Province of ______________) s.s.

City of __________________.)

AFFIDAVIT OF DAMAGE TO VEHICLE

I, YOCHABEL EURECA P. BORJE, of legal age, single, Filipino and a resident of 312
Callista, Levina Place, Pasig City, after having been duly sworn to in accordance with law
hereby depose and say:
1. That I am a duly licensed driver with Non-Professional Driver’s License No. N02-19-
018524 which is valid until January 15, 2024;

2. That on 23th day of November, at around 7:30AM, I drove to vehicle owned and
registered in the name of Richard Borje and Cherry Borje which is more particularly
described as follows:
Make: Honda
Series: Civic
Body Type: Sedan
Conduction Sticker No.: E2J572

3. That I drove the vehicle across Jenny’s Ave and GSIS Road to go to my office, I was not
able to estimate well the distance between the car that I was driving and the approaching
vehicle particularly a Ford Ranger along GSIS Road. I bumped into the Ford Ranger’s
side therefore causing damage to my front bumper. Also, a motorcycle that was on my
back accidentally hit me causing damage on my rear bumper as well. While I was
assessing the car later on, the accident caused damages on my front bumper, rear bumper,
and the lowest side portion of the left side door (passenger’s seat) of the motor vehicle.

4. 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 the vehicle.

IN WITNESS THEREOF, I have hereunto set/affixed my signature

this_______________ at _____________________________, Philippines.

YOCHABEL EURECA P. BORJE

Affiant

Drive’s License No. N02-19-018524

Issued by LTO

SUBSCRIBED AND SWORN TO before me this _______________________ at

________________________, Philippines.

Doc. No. ___

Page No. ___
Book No. ___
Republic of the Philippines)
Province of ______________) s.s.
City of __________________.)
Series of ___