Republic of the Philippines )

Province of Samar )
City of Calbayog )S.S.

AFFIDAVIT OF VEHICULAR ACCIDENT

KNOW ALL MEN BY THESE PRESENTS:

I, XUNRONG ZOU, of legal age, Chinese, married, and a resident of Brgy. Solsogon,
Sta. Margarita, Samar, Philippines, after having been sworn in accordance with law, hereby
deposes and states the following:

1. I am the authorized driver of one motor vehicle which is particularly described as

follows:
MAKE : Toyota
MODEL : Innova 2.0G
MV FILE NO. : 1380-00000598644
ENGINE NO. : 1TR6925197
CHASSIS NO. : TGN405021293
PLATE NO. : PSO846
2. That, I am holder of a Non Professional Driver’s License, No. C10-97-136401, issued
by the Department of Transportation Land Transportation Office;
3. On September 16, 2019 at around four o’clock in the afternoon, I was driving along
Maharlika Highway within the vicinity of Brgy. Tinambacan Norte, Calbayog City, going
northbound. In the same lane, ahead of me is a motorcycle which was also traversing
the National Highway. The road is straight ahead so I signaled that I intend to overtake.
And as I was about to overtake, the motorcycle made a sudden turn without signaling
that they are about to make a left turn. I managed to apply brake and maneuver the car
not to hit them but unfortunately to my dismay they suddenly come to halt at the center
of the road. My car hit the motorcycle. The accident happened so fast and went
beyond my control;
4. I am executing this affidavit to attest to the veracity of my statements and to support my
claims for reimbursement from the insurance company.

IN WITNESS WHEREOF, I have here unto affixed my signature this ___th day of
_______________ 2019.

XUNRONG ZOU
Affiant

SUBSCRIBED and SWORN TO before me on the ___th day of _______________

2019, Calbayog City, Samar, affiant exhibited to me his/her ___________________ issued on
__________________ at _______________, and who signed said document in my presence
and sworn as to said document that he understood the contents thereof and that the same was
his/her free and voluntary act and deed.

ATTY. JEFFREY R. BERNATE

Notary Public for Calbayog City and Province of Samar
Bernate Cmpd., P-1, Brgy. Capoocan, Calbayog City,
Samar
Roll No. 67531 / May 24, 2017
Doc. No. ______
IBP No. 066065 / Jan. 09, 2018 / Samar
Page No. ______
MCLE Compliance No. VI-0011184 / April 14, 2022
Book No. ______
PTR No. 5282535 / Jan. 04, 2019 / Calbayog City
Series of 2019
Notarial Commission No. 1908
Notarial Commission Expiration: Dec. 31, 2020

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