REPUBLIC OF THE PHILIPPINES)

________ CITY ) SS

AFFIDAVIT OF MOTOR VEHICLE ACCIDENT

I, _________________ Filipino, of legal age, with address at ________________________

___________________________________, after having been sworn to in accordance with law
hereby depose and state that:

1. That I am a duly licensed driver with Driver’s License No. ___________ which is valid until
________________.

2. That on ______________, at around _________, I was driving a motor vehicle particularly

described as follows:

OR No.: _____________________________
CR No.: _____________________________
Make: _____________________________
Chassis No.: _____________________________
Plate No.: _____________________________
Model: _____________________________
Motor No.: _____________________________

3. That I bumped the ___________ in front of me when I _______________ on ____________ at

__________________, damaging the ______________________.

AFFIANT FURTHER SAYETH NAUGHT

IN WITNESS WHEREOF, I hereby affix my signature this ____ day of ____________ in

___________ City.

_________________________________ ________________________________
Signature over Printed Name of Witness Signature over Printed Name of Affiant

SUBSCRIBED AND SWORN to before me, a Notary Public, this ___ day of ____________ 2019 at
_____________ City, affiant exhibited to me the following identification:

Name Identification Number Valid Until Place Issued

1.
2.

Doc. No. ;____

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