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Republic of the Philippines )

City of Quezon ) S.S.


x--------------------------x

AFFIDAVIT OF DAMAGE TO VEHICLE


I, EDZEL N. REYES, of legal age, Filipino citizen, and presently
residing at 19 Alton Street Area A, Batasan Hills Quezon City, driver of
SMART VAN, after having been duly sworn to in accordance with law, do
hereby depose and state:

1. That I am a duly licensed driver with Driver's License No.N02-08-017-


406 which is valid until 2017-07-10:

2. That on October 10, 2016, at around 7:00 am , I was driving a motor


vehicle owned and registered in my name which is more particularly
described as follows:

Make: Mitsubishi Motor No: 4D56AAL8001


Series: L 300 EXCEED Chassis No.: PAEL55MVFB017519
Body Type:CAB CHASSIS Plate No.: ADB 7761
Year Model:2015 MV FILE no.: 1303-00000135662

3. That while I was slowlyturning around the vehicle on my right side, in


a street near Maligaya Elementary School, the van suddenly hit the
roof of one store. That said roof is overlapping in the street, causing
the roof to touch and hit the upper right side of the van that I am
driving.

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


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___________in


Quezon City, Philippines.

_______________________________
EDZEL N. REYES
Affiant

SUBSCRIBED AND SWORN to before me this_______________ in


the City of Quezon, Philippines, affiant exhibiting to me her competent evidence
of identity by way of Driver's License No.N02-08-017-406 which is valid until
2017-07-10 issued at Quezon City, Philippines.

Doc No. : _____


Page No.: ______
Book No.: ______
Series of 2016