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Affidavit of Own Damage Form

The document is an affidavit from a vehicle owner in the Philippines describing damage to their vehicle from an incident. It states that on April 30th at 7pm, while driving home, a small rock hit their vehicle and damaged the front shield. The owner is filing this affidavit to support an insurance claim to repair the damage caused to their vehicle.

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Marichel
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370 views2 pages

Affidavit of Own Damage Form

The document is an affidavit from a vehicle owner in the Philippines describing damage to their vehicle from an incident. It states that on April 30th at 7pm, while driving home, a small rock hit their vehicle and damaged the front shield. The owner is filing this affidavit to support an insurance claim to repair the damage caused to their vehicle.

Uploaded by

Marichel
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Republic of the Philippines)

)S.S.
x--------------------------------------/
AFFIDAVIT OF OWN DAMAGE TO VEHICLE

I, __________________, of legal age, Filipino, married and presently


residing at _________________, Mandaue Cebu, Philippines after having
been duly sworn to in accordance with law, depose and say that:
1. That I am a duly licensed driver with Driver's License No.
_________, which is valid until ____________.

2. That on April 30, at around 7:00 in the evening, 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.:
Year Model: MV File No.:

3. That while I was on my way home, the aforementioned vehicle


was suddenly hit by a small rock at SRP Road and as a result the
said vehicle sustained damage at its front shield;

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


foregoing 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 _____
day of __________________, at __________________________,
Philippines.

_______________________
Affiant
Driver’s License No. ___________

SUBSCRIBED AND SWORN TO before me this ____day of


____________, at _________________________, Philippines, affiant
exhibiting to me his valid proof of identification as shown above.

Doc No. _______;


Page No. ______;
Book No. ______;
Series of 2022.

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