REPUBLIC OF THE PHILIPPINES)

CITY OF CEBU  ) S.S.

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AFFIDAVIT OF DAMAGE TO VEHICLE

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

________________________________________, after having been duly sworn to in accordance
with law, hereby depose and states:

1. That I am a duly licensed driver with Driver's License No._______, which is valid
until _______________.

2. That I am co-borrower of a car loan at RCBC Bank _____________, being the

principal borrower. That the said vehicle is particularly described as follows:

Make: Engine No.:

Series: Chassis No.:

Body Type: Plate No.:

Year Model: MV File No.:

3. That on or about __________________, I went to ________________________

driving the abovementioned vehicle;

3. That upon reaching the said destination, I parked the said vehicle at the parking
lot in a nose-in position. I immediately alighted from the said vehicle to purchase food at a
restaurant;

4. That thereafter, I went back to the said vehicle. Unknown to me, however, the
front side engine cover got snagged to a Precast Concrete Parking Curb or Bumper. Thus,
when I executed a reverse maneuver, a portion of the engine cover was detached causing a
friction to the surface of the pavement;

5. That I immediately alighted from the said vehicle to check the damage and
immediately thereafter, I brought the said vehicle to _________________________________;
 
6. That I executed this affidavit to attest to the truthfulness of the foregoing facts and
circumstances to support my insurance claim for own damage and for whatever legal purpose it
may serve.

IN WITNESS WHEREOF, I hereby affixed

my signature this ___________________ in the _________________, Philippines.
 ___________________________
Affiant

 SUBCRIBED AND SWORN TO before me this ___________________ in

_________________, Philippines, affiant exhibiting to me his/her competent evidence of identity
by way of _________________ issued at ______________ on __________________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2020.