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________________________ ) S.S.


I, JUAN DELA CRUZ, of legal age, Filipino, single, residing at

10000 J. Dela Cruz Street, Brgy. Salapan, San Juan City, after being
duly sworn to in accordance with law, hereby depose and state:

1. That I am a duly licensed driver with Non-Professional

Driver’s License No. N04-96-000000 which is valid until 30 November

2. That I am the authorized driver of a Mica Blue 2016 Toyota

Vios with conduction number YU 0808, registered in the name of my
brother-in-law, RICKY MARTIN, more particularly described as follows:

MAKE : Honda Engine No. : 1NZZ111111

Series : Vios 1.6G Gas M Chassis No.: NCP1500000003
Body Type: Sedan Conduction No: YU 1961

3. That on or about noon of 20 January 2018, while I was

backing at a friend’s house in Sto. Tomas, Batangas, I hit a big rock
causing damage to the left side near the back wheel and rear end of
the above-mentioned car.

4. That on or about 10:00 in the morning, 16 February 2018,

while my vehicle was parked outside our residence in Brgy. Salapan,
San Juan City, I noticed when I went out that the car had scratches
near the gas tank, a dent (before the roof), as well as scratches on the
left side body. Unfortunately, I did not see who caused the said

5. That on or about 11 March 2018, I saw the paint on the

right front side of the car scraped and the lower portion dented, as
well as my side skirt damaged. Unfortunately, I did not see who
caused it because it happened when the car was parked in Kamuning,
Quezon City.

6. On or about 8:00 p.m. of 25 May 2018, I got bumped by

another vehicle hitting my right rearview mirror and scratches but I
did not realize that I incurred such damages until I parked the car. The
incident happened along A. Bonifacio Avenue, Quezon City.

7. 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 my vehicle.
IN WITNESS WHEREOF, I have hereunto set my hand this
______ day in ______________, Metro Manila, Philippines.



SUBSCRIBED AND SWORN to before me this ___ day of

______________ at _____________.

Doc. No. ____

Page No. ____
Book No. ____
Series of 2018