REPUBLIC OF THE PHILIPPINES)

CITY OF QUEZON CITY

) S.S.

x----------------------------------x

AFFIDAVIT OF DAMAGE TO VEHICLE

I, X, of legal age, Filipino, married to Ma. Myrna M. Navarro, and a resident of X after having been duly sworn to
in accordance with law, depose and state THAT:

1. That I am a duly licensed driver with Driver's License No. X .

2. That on X, at around X, I was driving a X

owned and registered X

which is more particularly described as

follows;

Make: X
Series: X

Body Type: X

Plate No.: X

Year Model: X

MV File No.: X

3. That while I was driving towards X via the X, (insert description of accident)

4. 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 my vehicle

IN WITNESS WHEREOF, I have hereunto set my hand this X in Quezon City, Metro Manila, Philippines.

______________
Affiant
ID No. X

SUBCRIBED AND SWORN TO before me this ___________________ in _________________, Philippines,

affiant exhibiting to me his valid proof of identification.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2016.