Republic of the Philippines)

Cagayan de Oro City) S.S

DRIVER’S AFFIDAVIT OF ACCIDENT

I, , Filipino, of legal age, married, and a resident of Cagayan de Oro

City, after being sworn to in accordance with law, depose and state:

1. That I am a duly licensed driver with Driver's License No., which is valid
until 07 October 2019;

2. That on 23 December 2018 at around 8:30 in the morning, I was driving a

motor vehicle owned and registered in my name which is more particularly
described as follows:

Make: Toyota Motor No.:

Series: Fortuner 4x2 2. Chassis No.:
Body Type: SUV Plate No.:
Year Model: 2017 MV File No.:

3. That while I was slowly backing out of the parking lot of my residence, the
aforementioned vehicle suddenly hit both sides of the gate from where I was
backing out and as a result, the said vehicle sustained damages at both its
rear left side and rear right side;

4. That I am executing this Affidavit to attest to the truth of the foregoing and
in support of the claim against the insurer for the repair of the damage
caused to my vehicle.

IN WITNESS WHEREOF, I hereunto set my hand this

_______________ in Cagayan de Oro City, Philippines.

Affiant

SUBSCRIBED AND SWORN to before me this 17th day of January

2019 in the City of Cagayan de Oro, Philippines, affiant exhibiting to me her
Competent Evidence of Identity in the form of her Driver’s License No..

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2019.