Republic of the Philippines) S.S.

AFFIDAVIT OF DAMAGE TO VEHICLE

I, ____________, of legal age, married, Filipino, a resident of 8 Int. Boni
Serrano Road, Quezon City, and the driver of ____________, after being duly sworn
to in accordance with law, hereby deposite and state:
1. That I am a duly licensed driver with Professional Drivers License No. ___________
which is valid until April 15, 2018.
2. That on April 18, 2016 at around 9:00 oclock in the morning, I was driving a motor
vehicle owned and registered in the name of Mr. _________, which is more
particularly described as follows:
Make

TOYOTA

Model

2016 Fortuner 4x2 2.4L V AT

Chassis No.

________________

Conduction Sticker No.:

_________________

Color

Gray Metallic

3. That while I was parking the motor vehicle described in paragraph 2 above at the
basement parking area of Mr. ________s residence at ____________________, I
made a miscalculation of the space needed to properly park, which caused damage
to the front right side of the said vehicle.
4. That I am executing this Affidavit to attest to the truth of the foregoing and in support
of the claim against the insurer for the repair of the damage caused to the said
vehicle.
IN WITNESS WHEREOF, I have hereunto
_______________ at ____________________, Philippines.

set

my

hand

this

_________________
Affiant
SUBSCRIBED AND SWORN TO before me this __________________ at
___________________, affiant exhibiting to me his competent evidence of identity

by way of Drivers License no. ___________ issued at LTO, East Avenue, Quezon
City on April 16, 2015 and valid until April 15, 2018.

Doc. No. ____;

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