Republic of the Philippines )

City of Davao ) S.S

AFFIDAVIT OF DAMAGE TO VEHICLE

I, Christa Mira. A. Puertos, of legal age, Filipino, married and residing at Block 7, Lot 3, Mt.
Matutum St., La Vista Monte 1 Subdivision, Matina, Davao City, after being duly sworn to in
accordance with law do hereby depose and say:

1. That I am a duly licensed driver with Driver’s License No. L02-17-010022 which
is valid until March 16, 2022;

2. That I am the owner of a motor vehicle mortgaged to Toyota Financial Services

which is more particularly described as follows:

Make : TOYOTA WIGO

Model Year : 2020

Plate Number : LAI 2129

Color : ORANGE METALLIC

Chassis Number : MHKA4DEFLJ013430

Engine Number : 1KRA538612

3. That on Saturday night, April 10, 2021, heavy rains wreak havoc which caused
flash floods in various parts of Davao City;

4. That around 6:30pm of the same date, when I was traversing Matutum St. going
home then due to heavy rains occurred. The road I was traversing became
extremely flooded. As a result, since the floodwater rose instantly, the above-
described vehicle was suddenly submerged in floodwater which resulted to
severe damage;

5. 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 damaged caused to my
vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this ______________ at Davao

City, Philippines.
 CHRISTA MIRA. PUERTOS
Affiant

SUBSCRIBED AND SWORN to before me, this _____________, by Ms. Christa Mira A.
Puertos who exhibited to me her LTO Driver’s License No. L02-17-010022 issued at
Davao City valid until March 16, 2022, as competent proof of her identity.

Doc. No.
Page No.
Book No.
Series of 2021