Republic of the Philippines )

City of ) S.S.
x--------------x

AFFIDAVIT OF DAMAGE TO VEHICLE

I, xxx, of legal age, Filipino, with permanent address at xxx xxx, Muntinlupa City, after
having been sworn in accordance with law, hereby depose and state::

1. I am a duly licensed driver with Driver's License No. 0090909 valid until November
23, 2022;

2. The vehicle subject of this Affidavit is registered in my name and particularly

described as follows:

Make and Type Year Model Plate Number Engine No. Chassis No.
Hyundai 2018 vxhv Xxxx ddd cccccsx

3. While at the office, I received a phone call from my parents that my car was
smashed by another vehicle;

4. I was shocked to hear such news since my vehicle has always been regularly and
safely parked outside my current residence at xxx;

5. According to our neighbor ABC DDD, on 24 October 2018 at around 3:30 pm, he
heard a loud smash from the neighborhood. He immediately checked upon the
sudden noise and discovered that the rear part of my newly bought car has been
crashed;

6. While Mr. DDD did not exactly saw the incident, he knew that the noise he heard
came from a smashing car steel. He checked on the road and saw an elf driving
away from the incident. He can only surmise, however, that it was the elf vehicle
which crashed into my car. There is no CCTV recording in the area, which can
determine who caused the damage. Nevertheless, I do not foreclose the
possibility that another vehicle may have caused the said damage based on the
witness’ account and assessment from the appearance of the damaged surface;

7. I am executing this Affidavit to attest to the truth of the forgoing and in support of
the claims with the insurer for the repair of the damage caused to the said vehicle.

XXX

SUBSCRIBED AND SWORN TO BEFORE ME this _____th day of ____________________ in

________________________, Philippines affiant, exhibiting to me her ______________________
bearing the number __________________, valid until ___________________, issued in
________________, Philippines as competent proof of her identity.

Doc. No. ___

Page No. ___
Book No. ___
Series of 2018.