REPUBLIC OF THE PHILIPPINES QUEZON CITY

} }

S.S.

AFFIDAVIT OF VEHICULAR ACCIDENT of legal age, a resident of ______________________________________ after being sworn in accordance with law, hereby depose and say: That at present, I am jobless and a mere bystander. That on December 22, 2 !", at aro#nd ____________$time%, more or less, I was standing alongside of the di&ersion road near the intersection waiting for my friend Si 'a when the &ehic#lar accident happened. That while waiting for my friend, I had the time to watch and obser&e &ehicles passing along the di&ersion road. That I saw a tricycle loaded with passengers tra&ersing the right lane of the road heading towards the intersection. That while the said tricycle was approaching the intersection, s#ddenly a fast mo&ing &ehicle appeared and b#mped the former. That the fast mo&ing &ehicle was the 2

I, Tam Bay,

Single,

( )its#bishi *ancer +&ol#tion 'S,.

That there were people who get inj#red and died d#e to the &ehic#lar accident.
That I e-ec#te this .//ID.0IT to attest to the &eracity of the facts stated herein. Done this _____________ 2 !2 at 1#e2on 3ity.

_______________________________________ .ffiant 3T3. 4o. _______________________ Iss#ed on _______________________________ Iss#ed at _______________________________

S#bscribed and sworn to before me this ___________ day of _____________2 !2 at 1#e2on 3ity, 5hilippines. Doc. 4o. _______ 5age 4o. _______ Boo6 4o. ______ Series of 2 !2.