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(Affidavit of Damage to Vehicle Hitting a Post while Backing)

Republic of the Philippines)

Province of_________________) S.S.

City/Municipality of___________)

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

A F F ! A " #

$____________$Filipino$ of le%al a%e$&sin%le / 'arrie( / i(o)$an( a resi(ent

of__________$ Philippines$ after bein% sorn to in accor(ance ith la$ (epose an(

state*

+.#hat a' a (uly license( (river ith !river,s icense o._____________covere( by

!R o.___________$ hich is vali( until___________.

. #hat on___________$ at aroun(_______$ as (rivin% a 'otor vehicle one( an(

re%istere( in 'y na'e hich is 'ore particularly (escribe( as follos*

Ma0e____________ Motor o.*____________

Series*__________ Chassis o.*___________

1o(y #ype*___________Plate o.*_____________

2ear Mo(el*___________M"RR o.*____________

3. #hat hile as sloly bac0in% out of the (riveay

alon%__________Street$____________$to par0 'y car at the par0in% area

of___________$ the afore'entione( vehicle su((enly hit the post of the buil(in% fro'

7/25/2019 Affidavit of Damage to Vehicle Hitting a Post while Backing.doc

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here as bac0in% out an( as a result the sai( vehicle sustaine( (a'a%e at its

__________4

5. #hat a' executin% this Affi(avit to attest to the truth of the for%oin% an( in support ofthe clai' a%ainst the insurer for the repair of the (a'a%e cause( to 'y vehicle

6#7SS 687R79F$ have hereunto set 'y han(

this___________in___________$ Philippines.

AFFA#

&:;RA#)