Republic of the Philippines) S.S.

City of MANDAUE

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AFFIDAVIT OF DAMAGE TO VEHICLE
I, ISRAEL D. ALIN, Filipino, of legal age, married, and a resident of Briza Subd.,
Nangka, Consolacion, Cebu, Philippines, after being duly sworn to in accordance with
law, hereby depose and state:
1. That I am a duly licensed driver with Professional Driver's License No. G06-02067887 which is valid until 20 October 2016.
2. That on May 18, 2015, at around 3pm, in the parking area in my office located
at Tipolo Square Bldg., Tipolo, Mandaue City, I parked my motor vehicle owned and
registered in my name which is more particularly described as follows:
Make:
Series:
Body Type:
MV File No.:

SUBARU
FORESTER
WAGON
0701-00000080128

Engine No.: 1341729

Chassis No.: JF1SJ5LC5EG121413
Plate No.:
7AT-178671

3. That while I was slowly backing out of the driveway along Tipolo Street, Tipolo,
Mandaue City, to park my car at the parking area of Tipolo Square Bldg., the
aforementioned vehicle was suddenly bumped by another vehicle which was moving out
from the opposite side where I was backing out and as a result my vehicle sustained
damage at its back bumper;
4. That the said vehicle drove away without acknowledging its liability, therefore,
a case of hit and run that even the plate number of the vehicle was impossible to be
ascertained;
5. That there were no other persons 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 May 19,
2015 at City of Mandaue, Cebu, Philippines.

ISRAEL D. ALIN
Affiant
SUBSCRIBED AND SWORN to before me, this 19th day of May 2015, by
ISRAEL D. ALIN who exhibited to me his drivers license with license number G06-02067887 issued at East Avenue, Quezon City, Philippines on November 11, 2015 and
which will expire on October 20, 2016.

Notary Public

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2015.