REPUBLIC OF THE PHILIPPINES }

CITY OF MALABON } s.c.

AFFIDAVIT OF DAMAGE

I, XXX Filipino, of legal age, presently residing at No. 20 Metro

Heights Compound Barangay Culiat Quezon City, after being sworn in
accordance with law, deposes and states that:

1. That I am the a duly licensed driver with Driver's License

No: ______________ which is Valid until ____________.
Attached is the copy of my ID with its OR as Annex A;

2. That on May 15, 2016 at around 7:30 in the morning, I

was driving a motor vehicle owned and registered under
the name of my mother DOREZA C. MORANA. Attached is
a copy of the latest OR and CR as Annex B;

3. That the vehicle is more particularly described as follows:

Make: NISSAN
Series: COROLLA 1.6G AT
Chassis No: ZZE121-8024470
Body Type: SEDAN
Plate No: ABC 123
Year Model: 2007
MV FILE No: 0480-000012345

4. That when me and my mother were about to go to

church, I was the one driving the motor vehicle and park
inside the premise of Imus Cathedaral Church. After
mass, I was slowly backing out of the driveway at the
parking area when the said vehicle suddenly hit the post
of the building from where I was backing out and as a
result the said vehicle sustained damage at its right side
mirror broke and disjointed.

5. That due to necessity and exigency, I have temporarily

caused it to be glued to prevent total disjointing pending
repair. Attached is the copy of picture depicting the
broken side mirror as Annex C;

6. That I am executing this affidavit to attest to the veracity

of the foregoing statements of fact and in support of the
claim against insurer for the repair of the damage caused
to my vehicle.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this____ day of June 2016 in the City of Malabon, Philippines.

XXX
Affiant

SUBSCRIBED AND SWORN TO before me this______day of June

2016 hereat Malabon City. Affiant exhibiting to me her Drivers License no:
N02-05-00
NOTARY PUBLIC