REPUBLIC OF THE PHILIPPINES )

MAKATI CITY ) S.S

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

AFFIDAVIT OF DAMAGE TO VEHICLE

I, _____________________________, Filipino, of legal age, and with

residence address at ________________________________y, the
registered owner of a 2015 Honda Civic, after being duly sworn to in
accordance with law, hereby depose and state that:

1. I am a duly authorized and licensed driver with Non-Profession

Drivers License No.: ________________________, copy of which is
herein attached as Annex A;

2. I am the registered owner of a 2015 Honda Civic 1.8S, which is more

particularly described as follows:

Make: HONDA OR No.: ____________

Series: CIVIC CR No.: ____________
Body Type: Sedan Chassis No.: ____________
Conduction: _________ Engine No.: ____________
Plate No.: ___________________

Copy of my cars Official Receipt and Certificate of

Registration are attached as Annexes B and C,
respectively.

3. On _____________ while I was slowly turning my car as I enter the

parking area along ______________________, I did not notice that I
already rammed over the entrance pavement causing dents,
scratches and damages on the front bumper and side fender of my
car;

4. Furthermore, there were no traffic enforcers present therein at the

time of the incident as this happened on a Sunday;

5. I am executing this affidavit to attest to the truth of the foregoing

facts and in support of my claim against the insurer,
________________________, for the repair of the damages caused
by the said incident on my car.

IN WITNESS WHEREOF, I have hereunto set my hand on this ____ day

of _______ 2017.

________________________
Affiant
 SUBSCRIBED AND SWORN TO BEFORE ME this ___ day of ______
2017, affiant exhibited to me his Drivers License with
________________________, which will expire on __________________.

Doc. No.: ______

Page No.: _____
Book No.: _____
Series of 2017.