REPUBLIC OF THE PHILIPPINES)

CITY OF BATANGAS )SS.

AFFIDAVIT OF ACCIDENT
I, MYRA B. DE CASTRO, of legal age, Filipino citizen and a
resident of Pulo Road,Bolbok, Batangas City after having duly sworn in
accordance with law hereby deposes and states that:

1. I am the registered owner of a vehicle which is particularly

described as follows:

Make : TOYOTA
Engine No. : MB48741
Chassis No. : MHKM1BE2EBK002561
Body Type : WAGON
Series : AVANZA 1.3W A/T
Year Model : 2013
Plate No. : VFN898

2. On August 19, 2018 at around 11:30 in the morning, while I was

driving towards the parking of our house, I accidentally hit our
gate causing damages on the back door and right side of the
abovementioned vehicle;

3. The said vehicle is covered by an insurance policy of Alpha

Insurance & Surety Co., Inc with Policy No. PC-B2-
121112/18, period covered from June 20, 2018 to June 20,
2019;

4. I am executing this Affidavit to attest to the truth of the

foregoing, for the purpose of informing the insurer of such
occurrence and further, for whatever legal purpose this may
serve.

FURTHER AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this August 20,2018 at Batangas City.

MYRA B. DE CASTRO
Affiant

SUBSCRIBED AND SWORN to before me in the City of

Batangas this 20th of August 2018 by the Affiant who exhibiting to me
her Non-Professional Driver’s License with No. D01-13-005706.

Doc. No. 250A;

Page No. 51;
Book No.XXI;
Series of 2018.