Affidavit of Damage To Vehicle
Uploaded by
Richard GomezAffidavit of Damage To Vehicle
Uploaded by
Richard GomezREPUBLIC OF THE PHILIPPINES
)
City of Santiago ) S.S.
AFFIDAVIT OF DAMAGE TO VEHICLE
I, GIEL D. GOMEZ, of legal age, and a resident of
__________________________________, after having been duly sworn to in accordance
with law, do hereby depose and state that:
1. I am an owner of a motor vehicle described as follows:
Make:
Model:
Plate No.:
Color:
2. Likewise, I am a holder of a professional driver’s license duly registered with the
Land Transportation Office (LTO) with license number ___________________
with expiry date ________________;
3. That on _____________, at around_________, I parked the said motor vehicle
at____________;
4. That after an hour later, when I returned to the said vehicle, I was surprised as I
arrived to find the damaged portion of windshield of my motor vehicle that
needs repair;
5. The picture of the damaged windshield is hereto attached as Annex “A” and
copies of the OR/CR are hereto attached as Annex “C” and Annex “D”.;
6. That I am executing this Affidavit to attest to the truth of the foregoing and in
support of my claim on the insurance of the said motor vehicle;
7. I am executing this affidavit for purposes of insurance claim and to attest to the
truth of the foregoing statements.
IN WITNESS WHEREOF, I have hereunto affixed my signature this _____ day of
___________, 20____ at Santiago City, Philippines.
GIEL D. GOMEZ
Affiant
ID/Driver’s License: _______________
SUBSCRIBED AND SWORN TO BEFORE ME, this _____ day of ___________,
2021 personally appeared the above, exhibiting to me his competent evidence of
identity his shown above.
Doc. No. _______________:
Page No. ______________:
Book No. ______________:
Series of 2021.
