Republic of the Philippines}

Cagayan de Oro City………} S.S.

x-----------------//

AFFIDAVIT OF DAMAGE TO VEHICLE

I, Benzon L. Tadoy, Filipino, of legal age, married with residence address at

Zone 12B, Upper Carmen, Cagayan de Oro City, Philippines, after being duly sworn to in
accordance with law, hereby depose and state:

1. That I am a holder of valid Professional Driver’s License No.K02-93-556B7

2. That I am the authorized driver of a motor Vehicle (TOYOTA VIOS 2021)

registered at the land Transportation Office, Iligan City District Office in the name of,
MALGELYRI G. GULTIANO of P-7 Brgy Butadon Poblacion Kapatagan Lanao del Norte
and bears MV File No. 1101-00000604808;

3. That on May 13, 2023 at about 1:00 o’clock in the afternoon while the
said vehicle was park under a mango tree in the parking area of my house, a strong
wind blew causing a mango fruit to fall on the upper right side of the front windshield
of the said vehicle, which impact caused damage to it;

4. That I am executing this affidavit in order to attest to the truth of the

foregoing circumstances and for the purpose of reporting the matter to my insurance
office for insurance claims.
.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________, at

Cagayan de Oro City, Philippines.

BENZON L. TADOY
Affiant
Driver’s License No.K02-93-556B7

SUBSCRIBED AND SWORN TO BEFORE ME, this _____________, Cagayan

de Oro City, Philippines, I hereby certify that I have personally examined the herein
affiant and that I am fully satisfied that he voluntary executed and understood his
statements.

Doc No.:________;
Page No.:_______;
Book No.:_______;
Series of 2023: