Republic of the Philippines )

City of Malaybalay
) S.S.

AFFIDAVIT OF DAMAGE TO VEHICLE

That I, CYRIL JOHN C. NOVAL, of legal age, Filipino and a resident of P-2,
Kisolon, Sumilao, Bukidnon, after having been duly sworn to in accordance with the
law, do hereby depose and state, to wit:
1 That I am a duly licensed driver with Professional Drivers License No. K0307-001520 which is valid until June 18, 2015.
2 That I am an Account Officer of D Asian Hills Bank, Inc. assigned at
Dangcagan Branch;
3 That on February 11, 2015, I was driving a motor vehicle owned and
registered in the name of D Asian Hills Bank, Inc. which is more
particularly described as follows:

Model
Color
Plate No.
CR No.
OR No.

:
:

:
HONDA XRM 125
BLACK / WHITE
KP3216
:
11850692-02
:
000020110089468

That at about 10:00 pm more or less on the same day, the said motor
vehicle was allegedly burned while I was travelling going to Poblacion
Dangcagan, Bukidnon. As a result, some parts of it were totally damaged
such as the seat, air cleaner, wirings, covers among others;

That I went to Dangcagan Municipal Police Station to extract a police

blotter to report the incident as per Blotter Entry No. 399;

That I am executing this Affidavit to attest the truth of the foregoing facts
and in support of the claim against the insurer for the repair of the
damage caused to the said company vehicle.

IN WITNESS WHEREOF, we have hereunto affixed our signatures on this

____ day of _____________ 2015, at Malaybalay City, Bukidnon, Philippines.

CYRIL JOHN C. NOVAL

Affiant
SUBSCRIBE AND SWORN TO before me this _______ day of _______________
2015, at Malaybalay City, Bukidnon, affiant exhibiting to me his competent evidence
of identity with Valid ID No. 052812-09 issued by D Asian Hills Bank, Inc.
Doc. No. ________
Page No. ________
Book No.________
Series of 2015