Republic of the Philippines )

__________________________ ) S.S.

AFFIDAVIT OF DAMAGE
I, ELSA of legal age, Filipino citizen, married and a resident at Frozen Castle of England
after being duly sworn to in accordance with law, hereby depose and state that:

1. I am the registered owner of the motor vehicle described hereunder:

MAKE/SERIES : Magical Sleigh

YEAR MODEL : 2013
ENGINE NO. : G4LAF90990
CHASSIS NO. : 23131243
PLATE NO. : LET 1TG0

2. Unfortunately on March 13, 2019 at about 7:00 A.M., when I was driving the above-
described motor vehicle and maneuvering the same out of our garage in our residence, I
miscalculated the distance along my path while I was making a reverse. As a result
thereof, the motor vehicle which I was driving side swiped with our garage steel gate
wing of our garage situated on my left side during that time resulting to substantial
damages (Long Scratches &, Scrapes, Light Dents & Breakage) on its, Left Side Mirror,
LH Front Passsenger’s Door, LH Rear Passsenger’s Door of the subject motor vehicle;

3. Considering that the incident is due to my fault and can be classified as a self-accident,
I deemed it unnecessary to secure a Police Report/Traffic Investigation Report in
relation thereto;

4. In view thereof, I am executing the foregoing Affidavit in good faith to attest to the
truthfulness of the statements above for the purpose of filing an insurance claim with
the insurer and for whatever legal intents and purposes this may serve.

FURTHER AFFIANT SAYS NONE.

IN WITNESS WHEREOF, I have hereunto set my hand and affix my signature this
_____________________________ at ______________________________.

QUEEN ELSA
Affiant

SUBSCRIBED AND SWORN to before me this _______ day of _________________________

at ______________________________, affiant exhibiting to me her Royal Card ID valid until July
12, 2017, which serves as her Competent Evidence/Proof of Identity pursuant to the 2004
Rules on Notarial Practice.

Doc. No. ________;

Page No. ________;
Book No. ________;
Series of 2019.