Republic of the Philippines) S.S.

City of ___________ )

AFFIDAVIT OF DAMAGE TO VEHICLE

I, ___________________, Filipino, of legal age, with address at

______________________________________________________________, after being
duly sworn to in accordance with law, hereby depose and state:

1. That I am a duly licensed driver with Driver's License No.

________________________which is valid until _______________.

2. That on 23 February 2010, at around 7:30 pm, I was driving a vehicle, with
__________________________ in the passenger’s seat, owned and registered in the
name of ____________________________ which is more particularly described as
follows:

Make: Engine No.:

Series: Chassis No.:
Body Type: Plate No.:
MV File No.:

3. That while I was slowly driving along Santolan Street, Cubao towards EDSA, a
passenger Jeepney which was on the opposite lane going to Katipunan Road, suddenly
over took our traffic lane and the spare tire posed at the driver’s side of the jeepney hit
the left side mirror of our company vehicle. As a result, the entire left side mirror broke
off from the said car’s body and since that passenger jeepney was still moving forward,
the detached mirror was dragged onto the left side of our car causing dents and further
damage;

4. That the said passenger jeepney drove away without acknowledging its
liability, therefore, a case of “hit and run” that even the plate number of the jeepney was
impossible to be ascertained;

5. That there were no traffic enforcers at the time of the accident;

6. 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 the said
company vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of

February, 2010 at City of___________, Philippines.

AFFIANT
 SUBSCRIBED AND SWORN to before me, this __ day of ____________2010,
by ___________________________________who exhibited to me his driver’s license
with license number ____________issued at ___________on __________________ and
which will expire on __________

Notary Public

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of 2010.