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Affidavit of Damage: Shiela Dumuk Buenaventura

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Republic of the Philippines)

City of Davao )S.S.


x-----------------------------------x

AFFIDAVIT OF DAMAGE

I, SHIELA DUMUK BUENAVENTURA, of legal age, Filipino, married,


and a resident of Wellspring Village 2, Catalunan Pequeño, Davao City, after
having been duly sworn in accordance with law, hereby depose and state
that:

1. I am a duly licensed driver with Professional Driver’s License No.


L02-17-001482 valid until 09/23/2021, and a registered owner of a
motor vehicle more particularly described as follows:

Make : Toyota Hilux 2.4L 4x2


Engine No. : 2GDC385513
MV File No. : 1301-00001156044
Temp. Plate No. : A6K 728

2. On 31 July 2020, at around 6:30 PM, I was driving my motor


vehicle along the main highway of C.P. Garcia St., Buhangin, Davao
City heading home when another vehicle opposite my direction
suddenly overtook the vehicle in front of it and heading towards my
direction at a very fast speed and encroaching on my lane.

3. Thus, I instinctively swerve the steering wheel of the vehicle I was


driving towards the rightmost portion of the road in order to avoid
collision. As a result, my vehicle hit the pavement of the highway
thus causing damage on the tire at the right front side of the
vehicle.

4. I was not able to get the plate number of the other vehicle as it was
speeding away very fast heading towards the exit road of the city.

5. I am executing this Affidavit to attest to the truth and veracity of all


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 affixed my signature this


_______________ at Davao City, Philippines.

SHIELA DUMUK BUENAVENTURA


Affiant

SUBSCRIBED AND SWORN to before me this ______________ at


Davao City, Philippines. For purposes of evidence of identity, affiant
exhibited to me her driver’s license no. L02-17-001482 valid until
09/23/2021.

Doc. No. ___;


Page No. ___;
Book No. ___;
Series of 2020.

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