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Affidavit of Damage - Sample

The affidavit describes a vehicle accident that occurred on February 11, 2020. The driver hit a protruding steel gate while exiting a facility, causing dents and scratches to the right side of their vehicle. They are filing this affidavit to support an insurance claim to repair the vehicle damage. The driver owns the damaged vehicle and holds a valid driver's license. They signed the affidavit on February 12, 2020 to attest to the truth of the accident details.

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Liza Melgar
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451 views1 page

Affidavit of Damage - Sample

The affidavit describes a vehicle accident that occurred on February 11, 2020. The driver hit a protruding steel gate while exiting a facility, causing dents and scratches to the right side of their vehicle. They are filing this affidavit to support an insurance claim to repair the vehicle damage. The driver owns the damaged vehicle and holds a valid driver's license. They signed the affidavit on February 12, 2020 to attest to the truth of the accident details.

Uploaded by

Liza Melgar
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 )

PROVINCE OF ISABELA )
CITYOF ILAGAN )S.S
X--------------------------------------------x

AFFIDAVIT OF DAMAGE

I, ________, Filipino, of legal age, married, and a resident of ______,


Philippines, after being duly sworn in accordance with law, depose and state:

1. That I am the same person executing this affidavit;

2. That I am a holder Non-Professional Driver’s License No. ___ which is valid


until ____.

3. That I am the lawful owner of a certain motor vehicle bearing Plate No. ___;

4. That on February 11, 2020 at about 9:00 o’clock in the morning while I was
driving the above described motor vehicle and when I was about to pass
through the exit gate of__________, I did not notice the portion of the steel
gate that protrudes along my path, thus, hitting the same and causing dents and
scratches on the right side of my motor vehicle;

5. That the damaged parts or portion need necessary repairs and/or replacement
to restore the motor vehicle to its original condition or state;

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.

IN WITNESS WHEREOF, I have hereunto set my hand this 12th day of February
2020 at ___, Isabela, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this 12th day of February 2020 at____,
Isabela, affiant exhibiting to me her competent evidenced of her identity above-stated.

Doc. No.
Page No. Notary Public
Book No. 67
Series of 2020

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