REPUBLIC OF THE PHILIPPINES)

CITY OF _____________________)

AFFIDAVIT OF ACCIDENT

I, _______________, Filipino, of legal age, with residence address

_______________________, 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 AND MODEL :

SERIAL NUMBER :
ENGINE NUMBER :
PLATE NUMBER :

On June 20th, 2018 just before midnight, I proceeded to leave a parking slot inside Ayala 30th
at 30 Meralco Ave, Pasig, 1605 Metro Manila. As I was pulling out of the slot, I did not notice
a cement pillar on the left, which I grazed with my car’s driver side, including the door and
left side mirror. Two weeks later I brought the car to the Toyota service center in Pasig.

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.

_____________________
AFFIANT

SUBSCRIBED AND SWORN to before me this __________ day of __________, 2018 at

_______________________, Affiant exhibiting to me his/her Residence Certificate No. /
Valid Identification ____________________ issued at __________ on __________.

NOTARY PUBLIC

Doc. No. __________

Page No. __________
Book No. __________
Series of __________