(Affidavit of Damage to Vehicle 

  Cannibalized Vehicle)

REPUBLIC OF THE PHILIPPINES)

Province of ____________________)  S.S.
City/Municipality of _____________)
x-----------------------x

AFFIDAVIT

            I, _____________, of legal age, Filipino, (single / married / widow), and a resident of
_____________, Philippines, after being sworn in accordance with law, depose and state:

That I am the true and registered owner of a certain motor vehicle, more particularly
described as follows:

Make:              _____________
Motor No.:       _____________
Chassis No.:     _____________
Plate No.:         _____________

      

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

_______________________, which is valid until ______________.

That on _____________, at around _________, I parked the said motor vehicle at

_____________.

That after an _____________ later, when I returned to the said vehicle, I was surprised
as I arrived to find the _____________ of my motor vehicle stolen and my car
vandalized. There were scratches on the front right side of it, with its paintwork
damaged and needs repair.

That I am executing this Affidavit to attest to the truth of the foregoing and in support of
my claim on the insurance of the said motor vehicle.

            IN WITNESS WHEREOF, I have hereunto set my hand this _____________, the City
of _____________, Philippines.

AFFIANT

 
  

(JURAT)