REPUBLIC OF THE PHILIPPINES )

CALOOCAN CITY, METRO-MANILA ) S.S.

AFFIDAVIT of accident

I, xxxxxxxxxxxxxxxxxx, of legal age, Filipino, and with address at No.

129 Galino Street, Kalookan City, Metro-Manila, after having been sworn to
in accordance with law, hereby depose and say:

1. That I am a registered owner of a motor vehicle, Nissan Sentra

with Plate No. xxxxxxxxxxxxxxxxxxx;

2. That at or about 11:30 in the evening, 7 November 2011, I was

driving said vehicle together with my wife and daughter, traversing along
Roxas Blvd northbound, approaching the corner of U. N. Avenue, when the
vehicle I was driving was bumped by another vehicle at the left rear
portion, causing heavy dent, breaking the tail lights assembly, and
deforming the rear bumper.

3. That after the impact, I slowed down to pull over, to confront the
driver of the other vehicle. However, it instead sped away northward. I
tried to give chase and we were able to note the vehicle as a Mitsubishi
Pajero, which resembles a dirty white color, and the plate number is
xxxxxxxxxxxxxxxxxx.

4. That upon reaching the Anda Circle near Bonifacio Drive, said
Mitsubishi Pajero slowed down in the dimly-lit area. So I never attempted
to get near the vehicle as I sense something unusual for it to slow down in
the dimly lighted portion of the road, and out of fear for our security. When
the vehicle moved towards Del Pan Area, I turned right to Intramuros
towards home.

5. That I am executing this affidavit to attest to the truth of all the

foregoing facts and for all legal purposes and intent it may serve.

IN WITNESS WHEREOF, I have hereunto affix my signature this 8 th day

of November 2011 at Caloocan City, Metro-Manila.

xxxxxxxxxxxxxxxxx
Affiant
Drive. Lic. (Prof.) No. xxxxxxxxxxxxxx
Presented

Subscribed and Sworn to before me this 8 th day of November 2011 at

Caloocan City, metro-Manila.
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 2011.