Republic of the Philippines)

City of ____________) S.S.

x---------------------------------x

AFFIDAVIT OF INCIDENT
I, __________________, Filipino, of legal age, single, and a
resident of __________________________________, after having
been sworn to in accordance with law, do hereby depose and state
that:
1. That I am the authorized driver of that motor vehicle
registered under the name of __________________, which vehicle is
specifically described as follows:
MAKE :
MODEL :
PLATE NO . :
ENGINE NO. :
COLOR :
2. On _______________, at around ______ in the
morning/afternoon/evening, while I was ____________________, I
accidentally __________ the ______________________________,
which I did not see from the rearview and side mirrors;
3. The impact caused dents, scratches and a huge hollow on the
_______ side of the above described motor vehicle, particularly
damaging the _______________ thereof, and also caused scratches
on the _______________ of the said motor vehicle;
4. I am executing this affidavit to attest to the truth of the
foregoing circumstances, for purposes of claiming against the said
motor vehicle’s insurance, and for whatever legal purpose this may
serve.
IN WITNESS HEREOF, I have hereunto set my hands this
_____ day of ___________ at ____________ City, Philippines.

________________________
Affiant

SUBSCRIBED AND SWORN to before me, in the City of

___________________, Philippines.
Doc No.______
Page No._____
Book No._____
Series of 20___.