REPUBLIC OF THE PHILIPPINES. . . .

)
Province of Davao del Norte. . . . . . . . . ) Sc.
City of Tagum. . . . . . . . . . . . . . . . . . . . )
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AFFIDAVIT OF ACCIDENT
I, ALPHA FE L. OMEGA, Filipino, of legal age, with residence address at 1433
Barangay Sto. Niño Panabo City, Davao del Norte, after having been duly sworn to in
accordance with law, hereby, depose and say that:

I am the authorized driver of one motor vehicle which is particularly described as

follows:

MAKE: Chevrolet
SERIES: Trax LT
CERTIFICATE OF REGISTRATION: 260344000
ENGINE NUMBER : BB14NET 161400275
MOTOR VEHICLE NUMBER : 110100000288723
PLATE NUMBER : WD 3756

On August 11, 2017 at around seven o’clock in the morning, as I arrived home
from Montevista, Province of Compostela Valley, I noticed that the front off-road
bumper of the abovementioned vehicle was already torn apart. That with due diligence in
travelling to my destination, the said loss went beyond my control.

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.

ALPHA FE L. OMEGA
Affiant

SUBSCRIBED AND SWORN to before me this 14TH day of August, 2017 at

Tagum City, Affiant exhibiting to me her Professional Regulations Commission
Identification No. 0112998 issued at Davao City.

Doc. No. _____;

Page No. _____;
Book No._____;
Series of 2017.