REPUBLIC OF THE PHILIPPINES)

PARANAQUE CITY )S.S

AFFIDAVIT OF DAMAGE TO VEHICLE

I, LEOVIGILDA ROSALES CABULAY, of legal age, Filipino, single, and a resident of

No. 6866 Macan St., Clarmen Village, San Isidro, Paranaque City, after having been sworn to in
accordance with law, hereby depose and say that;

1. That I am the registered owner of a motor vehicle stated below:

MAKE HONDA
PLATE NO. NEQ-2099
SERIES BR-V- S-CUV
ENGINE NO. L15717335947
CLASSFICATION PRIVATE
CR NO. 436383590
YEAR MODEL 2021
MV FILE NO. 1366-00000424943

2. That I am duly licensed with Driver’s License N26-14-012959;

3. That sometime on July 13, 2023 at around 1:20 in the afternoon, that I reported at the traffic
bureau, the incident that happen in my car ( Annex “A” ), that in the said report I did not
notice that there was a damage at the rear side of the bumper of the motor vehicle; see
attachment Annex “B”

4. That I am executing this affidavit to attest to the truth of the foregoing facts and to support
my application for the claim of insurance of the said motor vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this , in the

City of Paranaque, Philippines.

LEOVIGILDA ROSALES CABULAY

Affiant
Driver’s License No. N26-14-012959

SUBSCRIBED AND SWORN to before me, in the City of Paranaque, this

.

Doc. No.:
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Series of 2023