REPUBLIC OF THE PHILIPPINES)

PROVINCE OF AKLAN )S.S.

MUNICIPALITY OF KALIBO )
x-------------------------x

AFFIDAVIT OF DAMAGE TO MOTOR VEHICLE

I, __________________, of legal age, married, Filipino, and a resident of Roxas Ave.

Ext., Kalibo, Aklan, after having been duly sworn to in accordance with law, do hereby depose
and say:

1. That I am a duly licensed driver with Driver's License No. ________________, which
is valid until 2019-02-10;

2. That I am an authorized driver of a Motor Vehicle with Plate No. ______ which is
owned and registered under the name of Elaine M. Tirol, said motor vehicle is more
particularly described as follows:

MAKE/TYPE ….…………… FORD/ RANGER 3.2L 4x4

ENGINE No. ….…………… PSA12612666
CHASSIS No. ….…………… MNCUNFF50JW833505
PLATE No. ….…………… ___________________
MV FILE No. ….…………… 1301-00001146245
CR No. ….…………… 314306532

3. That on November 1, 2018 at around 5:00 pm, I parked the said motor vehicle along
Cardinal Sin Avenue, Kalibo, Aklan, in front of Unitop;

4. That when I went back to the said vehicle around 6:00 pm to get some things, I noticed
that the the vehicle has been damaged, the driver (left) side of the vehicle suffered
scratches and dents, while the whole body (front, back and right side) of the vehicle
suffred damages in the form of multiple scratches;

5. That I am executing this Affidavit to attest to the truth of the forgoing for all legal
intents and purposes and in support of the claim against the insurer for the repair of
the damage caused to my vehicle

IN TESTIMONY WHEREOF, I have hereunto set my hand this 15th day of

November, 2018 at Kalibo, Aklan.

______________________
Affiant
DL ID Card No. ___________________;
Issued at Kalibo, Aklan;
Expires on 2019-02-10;

SUBSCRIBED AND SWORN to before me this 15th day of November, 2018 at

Kalibo, Aklan.

Doc. No. 379;

Page No. 77;
Book No. IX;
Series of 2018.