REPUBLIC OF THE PHILIPPINES )QUEZON CITY ) S.S. 

AFFIDAVIT OF CAR DAMAGE 

I, VIVIAN V. LAUREL, Filipino, of legal age, with residence and postal address at 247-A J.P. Rizal, Project 4, Quezon City, after having been sworn to in accordance with law do hereby depose and state, that: 

1. That I am the registered owner of a motor vehicle which is more particularly described, are as follows, to wit:

Make/Type/Series : Toyota ViosModel : 2015 E SeriesEngine No. : ____________________Chassis No. : ___________________ Plate No. : YR-5834

2. That on December 15, 2015, at around 9:00 P.M. passing through PNR railway, going to Buendia Ave., when the above vehicle that I was driving was inadvertently submerged into flood that brought by typhoon Onyok;

3. That due to above happenstance, the above mentioned vehicle sustained damage on its engine and its other components;

4. That I am executing this affidavit to attest to the truth of the foregoing instrument in compliance with the insurance claim requirements and for any legal purposes and intent this may serve.

 IN WITNESS WHEREOF, I have hereunto set my hand this 22nd day of December 2015, in

Quezon City.                   

VIVIAN V. LAURELAffiant                                           

        

  SUBSCRIBED AND SWORN to before me, this 22nd day of December 2015, in Quezon City. Affiant exhibiting his/her ID with No. N02-91-165242, Issued on March 30, 2015 at LTO.                                                                                              NOTARY PUBLICDoc No.______;Page No._____;Book No.______;Series of 2015.