Republic of the Philippines )C a l o o c a n   C i t y  
) S . S .

FIDAVIT of VEHICLE DAMAGE

I,
 ______ 
, of legal age, Filipino citizen, single, and a resident of ____,after being sworn to in accordance
with law, depose and state that! I a "   a d u l y l i c e n s e d d r i # e r w i t h   $ r i # e r % s
&icense 'o. __( I a "   a n   a u t h o r i z e d   d r i # e r   o f   a
 ___ 
with
Plate No. ___ 
 which is ownedby ____(* & a s t + u g u s t  ,  - !  , a t a b o u t !  - - i n t h e
a f t e r n o o n , I p a r / e d t h e s a i d "otor #ehicle outside our house at ____Caloocan
City. +fter ha#inglunch at about  --p."., I went to chec/ the said #ehicle. I
noticedthat the rear left portion of said "otor #ehicle as well as the left sideo f i t s
b o d y h a d b e e n d a " a g e d . 0 h e " o t o r # e h i c l e h a s d e n t s o n t h e said parts.1 I   a "
e 2 e c u t i n g t h i s + f f i d a # i t t o a t t e s t t o t h e t r u t h o f t h e f o r e g o i n g facts
and in support of the clai" against the insurer for the repair of t h e d a " a g e c a u s e d
t o s a i d # e h i c l e a n d f o r a l l l e g a l p u r p o s e s i t " a y ser#e.
IN WITNESS WHEREOF
, I ha#e hereunto set "y hand this !!
th
day of +ugust, -! in Caloocan City, Philippines. 
Affiant

I,
 ______ 
, of legal age, Filipino citizen, single, and a resident of ____,after being sworn to in accordance
with law, depose and state that! I a "   a d u l y l i c e n s e d d r i # e r w i t h   $ r i # e r % s
&icense 'o. __( I a "   a n   a u t h o r i z e d   d r i # e r   o f   a
 ___ 
with
Plate No. ___ 
 which is ownedby ____(* & a s t + u g u s t  ,  - !  , a t a b o u t !  - - i n t h e
a f t e r n o o n , I p a r / e d t h e s a i d "otor #ehicle outside our house at ____Caloocan
City. +fter ha#inglunch at about  --p."., I went to chec/ the said #ehicle. I
noticedthat the rear left portion of said "otor #ehicle as well as the left sideo f i t s
b o d y h a d b e e n d a " a g e d . 0 h e " o t o r # e h i c l e h a s d e n t s o n t h e said parts.1 I   a "
e 2 e c u t i n g t h i s + f f i d a # i t t o a t t e s t t o t h e t r u t h o f t h e f o r e g o i n g facts
and in support of the clai" against the insurer for the repair of t h e d a " a g e c a u s e d
t o s a i d # e h i c l e a n d f o r a l l l e g a l p u r p o s e s i t " a y ser#e.
IN WITNESS WHEREOF
, I ha#e hereunto set "y hand this !!
th
day of +ugust, -! in Caloocan City, Philippines. 
Affiant