REPUBLIC OF THE PHILIPPINES)

CITY OF TARLAC )

AFFIDAVIT OF SELF ACCIDENT

I, FREDDIE F. GRANIL, Filipino, of legal age, with residence address at Cardona,

Gerona, Tarlac, after having been duly sworn to in accordance with law, hereby, depose
and say that:

1. I am the authorized driver of one motor vehicle which is particularly

described as follows:

MAKE AND MODEL: HONDA MOBILIO

SERIAL NUMBER: MRHDD4870HP020536
MOTOR NUMBER: L15Z15521837
PLATE NUMBER:

2. Last May 9, 2018, at about 1:00 in the afternoon, as I was parking the said
motor vehicle at the designated parking space at our house, at Cardona,
Gerona, Tarlac, the left side of the vehicle hit a bicycle parked thereat which
carved scratches thereon;

3. I am executing this affidavit to attest to the truth of the foregoing statement

and in support of my claims for reimbursement from the insurance company.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at

Tarlac City, Philippines.

FREDDIE F. GRANIL
Affiant

SUBSCRIBED AND SWORN to before me this ____________ at Tarlac City,

Philippines.

NOTARY PUBLIC

Doc. No. _______;

Page No._______;
Book No._______;
Series of _______.