REPUBLIC OF THE PHILIPPINES

City of Zamboanga )) s.s

AFFIDAVIT OF ACCIDENT

I, XXXXXXXXXXXXX, Filipino, of legal age, married and a resident of San Roque,

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

1. I am the authorized driver of a truck which may be particularly described as

follows:

MAKE AND MODEL: xxxxxxxxxxx

CHASSIS NO.: xxxxxxxxxxxx

ENGINE NO.: xxxxxxxxxxxx

TEM. PLATE NUMBER: xxxxxxxxxx

2. On April 12, 2018 at around 8 o’clock in the morning, while I was

maneuvering the car to leave our house, due to the mud, the car accidentally hit the
wall causing slight damages on the front left portion of the car including the front left
door;

3. The accident caused no physical injury but the left forepart including the
left front door sustained damages but not affecting

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

statement and in support of my claims for repair in the insurance company.

xxxxxxxxxxxxxxxxxx
Affiant

SUBSCRIBED AND SWORN to before me this 14th day of February 14 at

Zamboanga City, affiant exhibiting to me her Driver’s License with number
xxxxxxxxxxxxxxxx.

Doc. No._____
Page No.____
Book No._____
Series of 2019.