Republic of the Philippines

Province of Cagayan )S.S.

City of Tuguegarao )

AFFIDAVIT OF DAMAGE TO VEHICLE

I, ROMUALDO M. BIRUNG, Filipino, of legal age, single, and a resident of

Cataggaman Nuevo, Tuguegarao City, Cagayan, Philippines, after having been sworn to
in accordance with law, depose and state:

1. That I am a duly licensed driver with Professional Driver’s License No. N11-67-
004827, which is valid until February 7, 2024;

2. That on May 24, 2019, I was driving a vehicle owned and registered under my
name which is particularly describe as follows:

Make: Toyota Engine No.: 1KD2783448

Series: HIACE GL GRANDIA Chassis No.: JTFRT13P8H8022474
Body Type: VAN Plate No.: NCA 6117
Year Model: 2018 MV File No.: 1380-00000969989

3. That at around 1:30 to 2:00 PM on said date, I attended the graduation of my

daughter at “Pambayang Dalubhasaan ng Marilao” at Abangan Norte, Marilao,
Bulacan;

4. That while I was slowly parking at the basketball court which was the designated
parking area at that time, I did not noticed the basketball post near the vacant
space where I parked;

5. That my attention was focused on the side mirror since I could hardly hear the
car’s censor due to the loud sound system of the school, and as a result, I
accidentally bumped the basketball post at the back;

6. That as a result, the vehicle sustained several damages to wit:

a. Disalignment of the back door
b. Broken window of the back door
c. Dented back door and rear bumper

7. 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
my vehicle.

IN WITNESS WHEREOF, I have hereunto set my hand this __________ in Tuguegarao

City, Philippines.

ROMUALDO M. BIRUNG
Affiant
Driver’s License: N11-67-004827
Issued by LTO – Tuguegarao City/
Senior Citizen ID No. 18-1521
Issued by OSCA- Tuguegarao City

SUBSCRIBED AND SWORN to before me this ___________________, in Tuguegarao

City, Cagayan, affiant exhibited to me her identifying documents stated above which is
competent evidence of identity in accordance with the 2004 Rules of Notarial Practice.

Doc No.: ___

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