Republic of the Philippines )

Pasay City )S.S.

AFFIDAVIT of VEHICLE DAMAGE

I, #########, of legal age, Filipino citizen, married, and a resident

of Marikina City, after being sworn to in accordance with law, depose and state
that:

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

and valid until ###########;

2 I am an authorized driver of a 2009 Toyota Fortuner with Plate No.

######### which is an official vehicle owned by the #########,
############;

3 Last ##############, at about 8:30 in the morning, I was driving

the said motor vehicle along ######### on the way to our head
office at #########. While coming to a full stop I accidentally rear-
ended the left side of a sedan (####### being driven by one
###########, causing the following damage to my vehicle: Cracked
right headlight, Scratches and deformity on the left side of the bumper,
Misalignment on the right side of the hood.

4 I am executing this Affidavit to attest to the truth of the foregoing facts

and in support of the claim against the insurer for the repair of the
damage caused to said vehicle and for all legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

########## of February, 2019 in Pasay City, Philippines.

###############
Affiant
SUBSCRIBED AND SWORN TO BEFORE ME this _____th day of February 2019
in Pasay City, Philippines by ############ who presented his Driver's
License with License No##########, valid until ##########, issued in
Manila, Philippines.

Doc No. :
Page No.:
Book No.:
Series of 2019.