VEHICLE CLAIM AFFIDAVIT FORMAT
1. Affidavit of Claimant
I, [Your Name], of [Claimant's Address], being duly sworn, do hereby state and declare the following:
2. Claimant Information
Claimant Name: [Your Name]
Date of Birth: [MM/DD/YYYY]
Address: [Claimant's Address]
Phone Number: [Claimant's Phone Number]
Email: [Your Email]
3. Vehicle Information
Make: [Vehicle Make]
Model: [Vehicle Model]
Year: [Vehicle Year]
Vehicle Identification Number (VIN): [Vehicle VIN]
License Plate Number: [License Plate Number]
Odometer Reading: [Current Odometer Reading]
4. Incident Details
Date of Incident: [MM/DD/YYYY]
Location of Incident: [Location of Incident]
Description of Incident: [Detailed description of the accident or incident]
Cause of Incident: [Cause, if applicable]
Involved Parties: [List any other individuals or vehicles involved in the incident]
5. Claim Information
Claim Number: [Claim Number, if applicable]
Insurance Company: [Insurance Company Name]
Policy Number: [Insurance Policy Number]
Amount Claimed: [Claimed Amount]
Claim Type: [Type of Claim, e.g., accident, theft, damage]
6. Affirmation
I affirm that the information provided in this affidavit is accurate and truthful to the best of my knowledge. I understand that any false statements made in this affidavit may result in legal consequences.
7. Signatures
For Claimant:
Signature: ___________________________
Name: [Your Name]
Job Title (if applicable): [Claimant’s Job Title]
Date: [MM/DD/YYYY]
For Witness (if applicable):
Signature: ___________________________
Name: [Witness Name]
Job Title (if applicable): [Witness Job Title]
Date: [MM/DD/YYYY]
8. Notary Acknowledgment
State of [State]
County of [County]
Subscribed and sworn to before me this [Day] day of [Month], [Year].
Notary Public: ___________________________
My Commission Expires: [MM/DD/YYYY]
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