Republic of the Philippines )

Quezon City, Metro Manila) s.s.

x---------------------------------------x

AFFIDAVIT OF DAMAGE TO VEHICLE

I, ______________________, of lega, after being duly sworn to in accordance with law,

hereby depose and state the following facts, to wit:

1. That I am the registered owner of a certain vehicle more particularly described as

follows:

Make and Model :

Year Model :
Color :
Serial No. :
Motor No. :
Conduction Sticker :

2. That I am a duly licensed driver with Non-Professional Driver’s License No.:

_______________ which is valid until the _________________;

3. That on the _____________ at around _____ o’clock in the evening, when my sister and
I was about to leave the house to go to the airport, we were shocked to find out that the
right side of the abovedescribed vehicle had scratches and dent;

4. That an unknown bystander stated that a white van bumped said vehicle and left hurriedly
without even checking the damages caused to the latter;

5. That I have no knowledge of facts indicating as to who was responsible for the damages
sustained by said vehicle;

6. That I am executing this Affidavit to attest to the truth of the foregoing and in support of
my insurance claim against the insurer for the repair of the damage cause to said vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this ______ day of

_____________, City of Manila, Philippines.

____________________________________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of ___________ at

__________________, affiant exhibited to me her Driver’s License No. __________ issued
_______________ and will expire on ______________.

NOTARY PUBLIC

Doc. No.:_____;
Page No.:_____;
Book No.:_____;
Series of 2022.