Republic of the Philippines )

City of _____ ) S.S

AFFIDAVIT OF DAMAGE TO VEHICLE

I, __________________, of legal age, Filipino, married, and a resident of

_____________________, after being sworn to in accordance with law, depose and state:

1. That on ____________ at around _____ A.M., I noticed many visible surface scratches on the right
bumper of my Toyota ____________. The car was parked outside our house the night before.

2. The said vehicle is owned and registered in my name and is more particularly described as follows:

Model: ____________
Color: ____________
Plate number: ________
Certificate of Registration No.: __________
LTO Official Receipt: ______________

3. As it was night time when the scratches were sustained by my car, no one noticed or heard any incident
causing the said damage to my vehicle while it was parked. Neither was there a CCTV recording in
the area which can determine who caused the damage, as such, I do not foreclose the possibility that
it was another vehicle who caused said damage.

4. That I am executing this Affidavit to attest to the truth of the forgoing and in support of the claim
with the insurer for the repair of the damage caused to my vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this ______th day of _____ in
_____ City, Philippines.

________________

SUBSCRIBED AND SWORN TO BEFORE ME this _____th day of ______ in ____ City,
Philippines, ______________ who presented his ______________, valid until
_________________, issued in ___________, Philippines.

Doc. No. ___

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