Republic of the Philippines)

City of___________) S.S.

AFFIDAVIT OF DAMAGE TO VEHICLE

I, Pedro Penduko, of legal age, Filipino, single/maried, and a

resident of ______________________, Philippines, after being sworn
to in accordance with law, depose and state that:

1. I am a duly licensed driver with Professional Driver’s License

No. ______________ which is valid until ____________________.

2. That on _________________ at about __________________, I

was driving a motor vehicle owned and registered under
the name __________________ which is particularly
described as follows:

Make and Model:

Engine Number:
Chassis Number:
Plate Number:
Body Type:
Series:
MV File No:

3. That while I was slowly maneuvering backward at the

Parking Space ___________________a vehicle
________________________, driven by ___________________,
holder of Professional Driver License No.____________
suddenly hit the _________________ of the vehicle that I was
driving. As a result thereof, the above-mentioned vehicle
incurred damages particularly _____________________.

4. That I am executing this Affidavit to attest to the truth of the

foregoing and in support of the claim with the insurer for
the repair of the damage caused to my vehicle.

IN WITNESS WHEREOF, I have hereunto set my hands this _______

day of _______________20____ at _____________.

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 Affiant

SUBSCRIBED AND SWORN to before me, this _____________, by

_____________ who exhibited to me (his/her) Community Tax
Certificate No. _____________ issued at _____________, Philippines
on _____________.

Notary Public

Doc. No. ____

Page No. ____
Book No. ____
Series of 20__.

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