Republic of the Philippines)

City of Dumaguete . . . . . . ) S.S.

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AFFIDAVIT
I, _________________________, of legal age, Filipino, married, and a resident
of Brgy. Daro, Dumaguete City, Negros Oriental, after having been sworn to in
accordance with the law, do hereby depose and say the following, to wit:

That I am a duly licensed driver with Driver’s License No.

_________________, which is valid until ________________-;

That sometime on March 30, 2017, at around 2:00 o’clock in the afternoon,
I was driving a motor vehicle I own and registered in the name of
___________________ which is more particularly described as follows:

Make: Engine No:

Model: O.R. No.:
Year Model: C.R. No.:
Body Type:

That I parked the abovementioned motor vehicle along Hibbard Avenue,

Dumaguete City, across Coco Grande Hotel and thereafter got out of the car.
When I returned to my motor vehicle, I realized that it had been hit by an
unknown automobile. As a result of the said incident, the following parts of the
motor vehicle were damaged:

a) Passenger side step board

b) Tailgate

That I am executing this Affidavit to attest to the truth of the foregoing

statements and in support of the claim against the insurer for the repair of the
damage caused to my vehicle.

IN WITNESS WHEREOF, I hereby affix my signature this ______________

at Dumaguete City, Negros Oriental, Philippines.

________________
Affiant

SUBSCRIBED AND SWORN TO before me this _______________ at

Dumaguete City, Negros Oriental, affiant exhibited to me his Driver’s License No.
________________, valid until ______________, and personally known to me to be
the same person who executed this instrument and that he attested that he
executed this instrument freely and voluntarily.

Doc. No. _______;

Page No. _______;
Book No. _______;
Series of 2017.