Republic of the Philippines )

City of ) S.S
X ------------------------------ X

AFFIDAVIT
I, _________________________, of legal age, single and residing at
_________________________, after having duly sworn to under oath hereby declares:

1. That I am the assignee of a 2014 Toyota Vios ___________ registered under

the name of __________________ and which motor vehicle is more
particularly described as follows:

Make/Model : TOYOTA VIOS 1.3J MT-AV

Plate No. :
Chassis No. :
Engine No. :
Color :

2. That on _______________, I reported to work and parked my car outside

the premises of __________________. That at about 6:30 in the evening
of the same date, when I went ___________________directly to the place
where I parked the car, I noticed that the car sustained damages, specifically
___________________,

3. That I inquired from the guards on duty if they saw any untoward incident, but
unfortunately, nobody witnessed the incident;

4. That at that time of the incident, I was not able to report to the Police
authorities, hence, no sketch and measurement was done;

5. That I am executing this affidavit to attest to the foregoing narration of facts and
for whatever legal purposes and intents this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 14th day of

July, ______________, Philippines.

Affiant

Signed in the presence of:

SUBSCRIBED AND SWORN TO BEFORE me this ___________________,

Affiant having presented her LTO Valid ID with _______________ which will expire on
________________, for identification purposes.