REPUBLIC OF THE PHILIPPINES )

PROVINCE OF BULACAN ) S.S.

AFFIDAVIT OF SELF- ACCIDENT

(Motor Vehicle)
I, RAJEN RAGOS ARCE, of legal age, single, Filipino, and a resident of Block 8 Lot
11 Earth St., Nepo Homes, Km. 37 Pulong Buhangin, Sta. Maria, Bulacan after having been duly
sworn to according to law, hereby depose and state:

That I am a holder of a Professional Drivers License No. C07-14-010821 issued by the

Land Transportation Office and valid until August 4, 2021;

That I am the authorized driver of MA. DONABELLE L. CARANZA who is the

registered owner of a vehicle more particularly described as follows:

Make : Toyota
Vehicle Model Details : Vios 1.3 E A/T – CQ-001
Conduction Sticker Number : P2X998
Chassis Number : PA1B13F30K4091702
Engine Number : 1NRX469948

That on December 28, 2019, while backing out the said vehicle along Cityland
Subdivision, Pulong Buhangin, Sta. Maria, Bulacan, I accidentally hit a tree and it resulted in
the slight indentation and scratches unto the rear part of the said vehicle;

That I have exercised extraordinary care and due diligence with the use of the
aforementioned vehicle and the above incident was beyond my control;

That I execute this AFFIDAVIT to attest to the veracity of the facts stated herein and for
insurance claims purposes.

IN WITNESS WHEREOF, I have hereunto set my hand on this 28th day of December
2019 at Sta. Maria, Bulacan.

RAJEN RAGOS ARCE

Affiant
ID No. C07-14-010821
Issued by: LTO

SUBSCRIBED AND SWORN TO before me this 28th day of December 2019 at Sta.
Maria, Bulacan.

Doc. No. ____

Page No. ____
Book No. XVIII
Series of 2019