REPUBLIC OF THE PHILIPPINES)

CITY OF __________________) SS

AFFIDAVIT OF DAMAGE TO VEHICLE

I, JONATHAN VARQUEZ of legal age, Filipino, with office address at BLOCK 16, MC ARTHUR
HIGHWAY, BARANGAY PARAISO, TARLAC CITY, after having been duly sworn in accordance with law, do
hereby depose and say:
That I am duly licensed driver with Driver’s License No. A02-95-049793 which is valid until July 26, 2024.
That on September 20, 2023 around 5:00 o’clock in the afternoon in a restaurant parking lot at Friendship
Highway, Angeles City, Pampanga, I was driving a vehicle owned and registered in the name of Known-You
Seed Philippines, Inc. which is more particularly described as follows:
Make & Type: Toyota SUV
Series: Fortuner 4x4 V
Engine No: 1GD4806891
Chassis No: MHFHA3FS6L0569342
MV File: 0301-00001231217
Plate Number: CAU8889
Year Model: 2020

That I was slowly parking the car inside parking lot when the rear potion of the said car incidentally hit
the road light pole causing damage to its left rear side and while adjusting the position of the car, the front
left side also hit the same pole causing scratch on the front of the car. That the said circumstance was
purely incidental due to the fact that the space was too narrow.
That I am executing this Affidavit to attest to the truth of the forgoing and in support of the claim
against the insurer for the repair of the damage caused to the vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this ________ day of __________________.

JONATHAN M. VARQUEZ
Affiant
Driver’s License No. A02-95-049793
Valid until July 26, 2024

SUBSCRIBED AND SWORN to before me this _________ day of ___________, 20_____ in the City of
__________, affiant having exhibited to me his/her Driver’s License No. A02-95-049793 Valid until July 26,
2024.
Doc. No. ______
Page No. ______
Book No. ______
Series of ______