Republic of the Philippines }

City of Cebu } s.s.

AFFIDAVIT OF INCIDENT

I, , of legal age, Filipino, and a resident of

after being sworn in accordance with law, hereby depose and state that:

1. I am a duly licensed driver with Professional License No.

2. I am in possession of a vehicle registered in my name and is more
particularly described as follows:

Make: Engine No.:

Series: Chasis No.:
Body Type: Plate No:
MV File No.:

3. (actual event) ;

4. I am executing this affidavit to attest the truthfulness of the foregoing, in

support of the claim with the insurer for the repair of the damage caused
to my vehicle and for whatever legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

in the City of Cebu, Philippines

Affiant
Type of ID:
ID Number:

SUBSCRIBED AND SWORN to before me this ______ day of ______________ 2019 at

Cebu City by the above-mentioned person who exhibited to me his competent evidence
of identity with his photograph appearing thereon sufficient to prove his identity.

NOTARY PUBLIC

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