Republic of the Philippines)

)S.S.
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AFFIDAVIT OF OWN DAMAGE TO VEHICLE

I, __________________, of legal age, Filipino, married and presently

residing at _________________, Mandaue Cebu, Philippines after having
been duly sworn to in accordance with law, depose and say that:
1. That I am a duly licensed driver with Driver's License No.
_________, which is valid until ____________.

2. That on April 30, at around 7:00 in the evening, I was driving a

vehicle owned and registered in my name which is more
particularly described as follows:
Make : Engine No.:
Series: Chassis No.:
Body Type : Plate No.:
Year Model: MV File No.:

3. That while I was on my way home, the aforementioned vehicle

was suddenly hit by a small rock at SRP Road and as a result the
said vehicle sustained damage at its front shield;

4. That I am executing this Affidavit to attest to the truth of the

foregoing and in support of the claim against the insurer for the
repair of the damage caused to my vehicle.
IN WITNESS WHEREOF, I have hereunto set my hand this _____
day of __________________, at __________________________,
Philippines.

_______________________
Affiant
Driver’s License No. ___________

SUBSCRIBED AND SWORN TO before me this ____day of

____________, at _________________________, Philippines, affiant
exhibiting to me his valid proof of identification as shown above.

Doc No. _______;

Page No. ______;
Book No. ______;
Series of 2022.