Republic
of the Philippines )
City of _______________ ) S.S
AFFIDAVIT OF DAMAGE TO VEHICLE
I, (NAME OF AFFIANT),
Filipino, of legal age, married, and a resident of (Residential Address of Affiant), after being sworn
to in accordance with law, depose and state –
THAT:
1. I am a duly licensed driver with Driver's
License No. _________________ which is valid until ____________________;
2. On (Date of Incident) at around (Time of Incident), I
was driving a vehicle owned and registered in my name, which is more
particularly described as follows:
Make: _____________ Engine
No.: _____________
Series: _____________ Chassis No.: _____________
Body Type: _____________ Plate No: _____________
Color: _____________ MV File No.: _____________
3. I was passing along (Place of Incident) when I suddenly encountered a (Details of Vehicle B) with plate number _______________, driven by (Name of Driver) and registered under the name (Name of Owner of Vehicle B);
4. In my point of view at that moment, the (Details of the Incident; causes and circumstances). (Details of the Damage to Vehicle);
5. There was no traffic enforcer at the time
of the accident;
6. 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 (Date) in (Place), Philippines.
(NAME OF AFFIANT)
SUBSCRIBED AND SWORN TO BEFORE ME this (Date) in (Place) by (Name of Affiant) who presented his (ID Details)
which expires on (Expiry Date) and issued at (Place of Issue).
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2017.
