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Affidavit of Own Damage

1) The affiant noticed damage to their vehicle parked in their office parking lot, with the right side mirror broken and surface scratches on the right side. 2) An investigation by the security guard did not find any incidents that could have caused the damage. CCTV also did not show what caused it. 3) The affiant is filing this affidavit to support an insurance claim to repair the vehicle and attest to the truth of the events.

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2K views1 page

Affidavit of Own Damage

1) The affiant noticed damage to their vehicle parked in their office parking lot, with the right side mirror broken and surface scratches on the right side. 2) An investigation by the security guard did not find any incidents that could have caused the damage. CCTV also did not show what caused it. 3) The affiant is filing this affidavit to support an insurance claim to repair the vehicle and attest to the truth of the events.

Uploaded by

pam
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 )

)
) S.c.
x-----------------------------------x

AFFIDAVIT OF DAMAGE TO VEHICLE

I, ________________, Filipino, of legal age, single, and residing at


_________________________, after having been sworn to in accordance with law,
hereby depose and state the following:

1. That I am a duly licensed driver with Driver's License No. ______________ which
is valid until __________________;

2. That on _________________, after getting out from our office in


_____________________ where I usually parked my car, I noticed that my side
mirror on the right was broken and there’s a visible surface scratches on the said
side.

3. The said vehicle is owned and registered in my name and is more particularly
described as follows:

Make:
Color:
Series:
Engine No.:
Plate number:
Certificate of Registration No.:
LTO Official Receipt:

4. That the security guard on duty declared to having not noticed or heard any
incident causing the said damage to my vehicle while it was in the parking lot.
Neither was there a CCTV recording in the area which can determine who caused
the damage, as such, I do not foreclose the possibility that it was another vehicle
who caused said damage.

5. That I am executing this Affidavit to attest to the truth of the forgoing and in support
of the claim with the insurer for the repair of the damage caused to my vehicle and
for all legal intents and purposes that this affidavit may serve.

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


__________ 2020, in the ______________________.

___________________
Affiant

SUBSCRIBED AND SWORN to before me on this ___th day of ________ 2020,


in the ___________________, the affiant exhibiting to me his Driver’s License with No.
__________________ valid until ________________.

NOTARY PUBLIC

Doc No.:____;
Page No.:___;
Series of 2020.

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