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    Affidavit of Own Damage

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    Alfons Janssen Alpoy Marcera
    insurance claim the affiant must state the facts and circumstances on how the vehicle for example was damaged

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    Affidavit of Own Damage

    Uploaded by

    Alfons Janssen Alpoy Marcera
    7K views1 page
    insurance claim the affiant must state the facts and circumstances on how the vehicle for example was damaged

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    © © All Rights Reserved

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    insurance claim the affiant must state the facts and circumstances on how the vehicle for example was damaged

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    7K views1 page

    Affidavit of Own Damage

    Uploaded by

    Alfons Janssen Alpoy Marcera
    insurance claim the affiant must state the facts and circumstances on how the vehicle for example was damaged

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    Republic of the Philippines )

    Bacolod, Lanao del Norte ) S.S.

    AFFIDAVIT

    I, RICKY C. SUCUANO, of legal age, married, Filipino and a resident of Purok


    6, Poblacion, Bacolod, Lanao del Norte, after having been sworn in accordance with
    law, depose and state:

    1) That I am the Driver of Mitsubishi L300, owned by Bacolod Water District, the
    said vehicle is identified as follows:

    Brand: Mitsubishi
    Model/Year/Color: 1998
    Engine No.: 4D56A-EE4773
    Serial/Chassis No.: L039PYZL-04816
    Certificate of Registration No.: 1393083-6
    Official Receipt No. : 1552829865
    Plate No. : SHS-392

    2) That on August 16, 2019 while driving the said vehicle, I met an accident with
    one Yamaha Sniper 150 MXI driven by Brandon James T. Roldan at Poblacion, Bacolod,
    Lanao del Norte;
    3) As a result thereof, the vehicle that I am driving sustained damage to wit: the
    bumper and the left side signal light;
    4) That I am executing this affidavit to attest to the truth of the foregoing, for
    making an insurance claim, and for whatever other legal purposes this affidavit may
    serve.

    IN WITNESS WHEREOF, I have hereunto set my hand this 11th day of


    September 2019 in Bacolod, Lanao del Norte.

    RICKY C. SUCUANO
    Affiant

    SUBSCRIBED AND SWORN TO before me this 6th day of 11th day of September
    2019 in Bacolod, Lanao del Norte, affiant personally appearing and known to me to be
    the same person who executed the foregoing instrument, exhibiting his Driver’s License
    M02-08-000317 issued in Iligan City.

    WITNESS MY HAND AND SEAL.

    ATTY. ALFONS JANSSEN P. MARCERA


    Notary Public
    Serial No. 19-229
    Iligan City- Lanao del Norte
    Until December 31, 2020
    Doc. No. : 61; IBP Lifetime No. 01840
    Page No. : 13; Roll No. 70427- July 31, 2017
    Book No. : VIII; PTR No. 3838881- January 8,2019
    Series of 2019. MCLE Compliance No VI- 0022669- 8-18-18

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