Republic
of the Philippines )
City
of Cebu ) S.S
AFFIDAVIT OF DAMAGE TO VEHICLE
I, MEDIO Y. SUERTE, of legal age, Filipino,
married, and a resident of Cabangcalan, Mandaue City, Cebu, Philippines, after
being sworn to in accordance with law, depose and state:
1. That I am a duly
licensed driver with Driver's License No. XOXO12345 which is valid until 11-03-2018.
2. That on October 29, 2015
at around 10:00 A.M., after getting out from my tutorial session at English Only Please Tutorials in Plaza Sugbo, Paseo Trinidad, Gorordo Avenue, Cebu City, I noticed many visible surface
scratches on the front bumper of my Ford Ranger at the driver’s side near the fender, at
the parking area of said plaza.
3. The said vehicle is owned
and registered in my name and is more particularly described as follows:
Model: Ford Ranger Model 2015
Color: Silver Gray
Plate number: ABC6789
Certificate of
Registration No.: 143445678
LTO Official Receipt: 99783BHGAH0
4. That the security guard
on duty declared to having not noticed or heard any incident causing the said
damage to my vehicle while it was in the parking lot. Neither was there a CCTV
recording in the area which can determine who caused the damage, as such, I do
not foreclose the possibility that it was another vehicle who caused said
damage.
5. That I am executing this
Affidavit to attest to the truth of the forgoing 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 hand this ______th day of October 2015 in Cebu
City, Philippines.
MEDIO Y. SUERTE
SUBSCRIBED AND SWORN TO
BEFORE ME this _____th day of October 2015 in Cebu City, Philippines
by Medio Y. Suerte who presented his Philippine Passport No. XY10982392, valid until December 28, 2021, issued in Manila, Philippines.
Doc.
No. ___
Page
No. ___
Book
No. ___
Series
of 2015.